Nurse Reviewer (Associate or Level I) - AIM Specialty Health

Nurse Reviewer (Associate or Level I) - AIM Specialty Health

24 Dec 2024
California, Lamirada, 90637 Lamirada USA

Nurse Reviewer (Associate or Level I) - AIM Specialty Health

Vacancy expired!

Description SHIFT: Day JobSCHEDULE: Full-timeYour 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 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, but preference will be given to those that reside within 100 miles of Glendale, CaliforniaSchedule: Monday - Friday, 9:30 am to 6:00 pm PST. Target Start Date: February 15, 2021Salary: $31.21 per hour for the Associate level

$33.86 per hour for the Reviewer I

Please note that the level offered is determined by the Hiring Manager based on experience. 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 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 RequirementAccess 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 has been named a 2019 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.REQNUMBER: PS43094-California

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