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Anthem, Inc. Nurse Reviewer (Associate or Level I) in West Covina, California

Description

SHIFT: Day Job

SCHEDULE: Full-time

Be part of an extraordinary team

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high performance culture that empowers you to make an impact?

The use of this job is limited to the AIM business unit. If you believe this to be the best match for your position, please consult with your Human Resources partner prior to using this job (HRBP should work with Compensation).

The Nurse Reviewer I is responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

Primary duties may include, but are not limited to:

  • Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

  • Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.

  • Notifies ordering physician or rendering service provider office of the preauthorization determination decision.

  • Follows-up to obtain additional clinical information.

  • Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

The Nurse Reviewer Associate are responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment.

Primary duties may include, but are not limited to:

  • Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.

  • Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.

  • Notifies ordering physician or rendering service provider office of the preauthorization determination decision.

  • Follows-up to obtain additional clinical information.

  • Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.

Qualifications

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 I primary requirements:

  • Requires AS in nursing

  • Minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting

  • Minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience

  • Any combination of education and experience, which would provide an equivalent background.

  • Current unrestricted RN license in applicable state(s) required.

Nurse Reviewer I preferred requirements:

  • Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding

  • Managed health care including HMO, PO and POS plans strongly preferred.

  • BA/BS degree preferred.

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

Nurse Reviewer Associate primary requirements:

  • Requires AS in nursing

  • Minimum of 3 years of clinical nursing experience in an ambulatory or hospital setting

  • Minimum of 1 year of prior utilization management, medical management and/or quality management, and/or call center experience

  • Any combination of education and experience, which would provide an equivalent background.

  • Current unrestricted RN license in applicable state(s) required.

Nurse Reviewer Associate preferred requirements:

  • Familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans strongly preferred.

  • BA/BS degree preferred.

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

    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. The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Anthem is able to reasonably accommodate. Anthem will also follow all relevant federal, state and local laws. Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at careers.antheminc.com. Anthem is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact ability@icareerhelp.com for assistance.

    REQNUMBER: PS73932

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