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Nurse Reviewer Associate or Reviewer I

Location: , CA
Job Family: Medical
Req #: PS41453
Date Posted: Jan 25, 2021


SHIFT: Day Job

SCHEDULE: Full-time

Your Talent. Our Vision. At AIM Specialty Health (AIM), a proud member of the Anthem, Inc. family of companies, it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve. Nurse Reviewers (Associate or Level I) are responsible for conducting pre-authorization, out of network and appropriateness of treatment reviews for diagnostic imaging and other services by utilizing appropriate policies, clinical and department guidelines. They collaborate with healthcare providers to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. 

These positions typically require office training, but due to COVID our offices are currently closed. We have approval to offer remote/virtual training and these positions will work full-time remote from home. 
Locations considered (listed in order of importance): 
1. Los Angeles, California (Glendale, CA area) 
2. Anywhere in California - must reside in CA 

The schedule for this position is Monday - Friday, 9:30am to 6:00 pm PST. 

Primary duties may include, but are not limited to: 
- Receives pre-authorization requests from front-line intake 
- Conducts initial medical necessity clinical screening 
- Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review 
- Conducts initial medical necessity review of out of network pre-authorization requests for services requested outside of the client health plan network 
- Notifies ordering physician or rendering service provider office of the pre-authorization determination decision 
- Documents the results of the initial clinical review and determination in the pre-certification computer system 
- Maintains confidentiality of patient and provider specific information 
- Develops telephone service standards to meet departmental performance metrics 


Nurse Reviewer (Associate or Level I) 
SHARED qualifications: 
- Current active, valid unrestricted RN license 
- Candidates must have good computer skills and solid typing speed and accuracy 
- Knowledge of managed healthcare programs 
- HMO, PPO, and POS are preferred 
- Familiarity with Utilization Management Guidelines preferred 
- Familiarity with ICD-9 and CPT 4 coding preferred 

Nurse Reviewer Associate specific qualifications: 
- Graduate of an accredited school of nursing 
- Customer service experience is preferred - Quality management and/or call center experience is a plus 
- Any experience in clinical nursing experience is a plus 

Nurse Reviewer I specific qualifications:
- 3 + years recent clinical nursing experience in an ambulatory or hospital setting 
- Previous utilization and/or quality management and/or call center experience is helpful 

Additional Requirement: Access to the Internet with the following characteristics: 
- Minimum download speed of 10 megabytes per second (mbps) / upload speed of 3 megabytes per second (mbps) is required 

 Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2018 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. 
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