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Nurse Reviewer (Associate or Level I)

Location: CA
JobFamily: Medical
Req #: PS59084
Date Posted: Oct 23, 2021

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Description:

Description

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.  

 

**********$5,000 Sign-On Bonus**********

 

Nurse Reviewers 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. 
 
Location: Work from home 
Schedule: Monday - Friday, 9:30 am to 6:00 pm

Internet Requirement: Minimum download speed of 20 megabytes per second (mbps) / upload speed of 5 megabytes per second (mbps) 



Nurse Reviewer (Associate or Level I) 
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

Qualifications

Qualifications:

Nurse Reviewer Associate Requirements: 

  • Current active, valid, unrestricted RN license.
  • Knowledge of managed healthcare programs.

Nurse Reviewer Associate Preferred Qualifications:  

  • Customer service experience is preferred.
  • Quality management and/or call center experience is a plus 
  • Any experience in clinical nursing experience is a plus 
  • HMO, PPO, and POS are preferred.
  • Familiarity with Utilization Management Guidelines preferred.
  • Familiarity with ICD-10 and CPT 4 coding preferred.

 

Nurse Reviewer I Requirements:

  • Requires AS/BS in nursing from an accredited institution.
  • Current valid and unrestricted RN license in applicable state(s) required.
  • 3+ years of clinical nursing experience in an ambulatory or hospital setting or 1 year of prior utilization management, medical management and/or quality management, and/or call center experience
  • Requires familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PPO and POS plans.

Nurse Reviewer I Preferred Qualifications:  

 

  • Previous utilization and/or quality management and/or call center experience preferred.

 

Nurse Reviewer (Associate or Level I) Soft Skills:

  • Candidates must have good computer skills and solid typing speed and accuracy.

 


We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

Please be advised that Anthem only accepts resumes from agencies that have a signed agreement with Anthem. Accordingly, Anthem is not obligated to pay referral fees to any agency that is not a party to an agreement with Anthem. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Anthem.