Nurse Reviewer I - Anthem, Inc (California)
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. 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 PST. Target Start Date: June 7th, 2021 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 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
REQNUMBER: PS47878
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