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Nurse Reviewer Assoc of Nurse Reviewer I

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Medical
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PS27155 Requisition #

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. 

 

Note: These positions may be filled at the Associate or Level l role and will be determined based on experience, knowledge, and skills.

 
Location: Westchester, IL Office
 

The Nurse Reviewer Associate 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. Primary duties may include, but are not limited to:

  • Collaborates 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.

  • Receives preauthorization 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 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.

  • Documents the results of the initial clinical review and determination in the precertification computer system.

  • Maintains confidentiality of patient and provider specific information.

  • Develops telephone service standards to meet departmental performance metrics.

 

The Nurse Reviewer l 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 requires:

  • AS/BS in nursing; 1 year of experience; or any combination of education and experience, which would provide an equivalent background.

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

  • Familiarity with managed health care programs including HMO, PPO, and POS and with ICD-9 and CPT 4 coding preferred.

 

The Nurse Reviewer l requires:

  • AS/BS in nursing; 3 years of clinical nursing experience in an ambulatory or hospital setting; or any combination of education and experience, which would provide an equivalent background.

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

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

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

 
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 careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran.

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Associate Benefits

At Anthem, we're in the business of taking care of people. In fact, everything we do is aimed at creating positive outcomes that make a difference in peoples’ lives, which of course includes our family of associates.

That's why we're proud to offer strong benefits that maximize associates' satisfaction and performance, while also driving strong corporate results. Our Total Rewards program is a comprehensive benefits package that supports greater quality of life for our associates, personally and professionally, through a wide range of thoughtful offerings, including:

At Anthem we believe in creating shared success with our associates. That’s why we provide numerous benefits to help you plan for your financial future and achieve your personal and professional goals, including:

  • 401(k) Retirement Savings Plan – Associates may participate upon hire and are eligible for matching company contributions after one year of service.
  • Employee Stock Purchase Plan (ESPP) – As a public company, we have the opportunity to share our success through stock ownership. The ESPP gives you the opportunity to purchase Anthem, Inc. stock at a small discount, through convenient payroll deductions.
  • Life Insurance – Associate, spouse/domestic partner, and/or child(ren) coverage
  • Long – term Disability Plan
  • Financial Education Resources

At Anthem, we believe people should never stop learning and growing. That’s why we support our associates with a dynamic variety of Career Development benefits, including:

  • Tuition Assistance – Anthem can provide up to $5,000 in tax-free reimbursement each year to cover the cost of tuition, required fees, and textbooks at an accredited institution.
  • Certification Awards – To recognize certain certification achievements, we may reward your efforts with a monetary award.
  • Service Recognition Awards – We celebrate your commitment to the company by offering service awards at five-year milestones and upon retirement.
  • Learning and Development – At Anthem, personal development is imperative to our success. That’s why we provide associates a wide variety of flexible development opportunities. Access to online classes, on-demand resources, instructor-led workshops, and on-the-job training tools come together to create a culture of growth and development.

At Anthem, we believe hard work, perseverance and success should be rewarded. That’s why we provide a strong compensation package that recognizes the valuable contributions each associate brings to our organization, In addition to competitive salaries, we offer:

  • Base Pay – Our base compensation system is market-driven and built to differentiate among individuals based on performance and competencies.
  • Merit Increases – Base pay merit increases are determined by your performance and pay relative to market data.
  • Incentive Programs – We believe that results improve when we are all aligned as one company working together to achieve common goals. To ensure we all share in Anthem's success, we offer incentive programs so that you are rewarded when the company, your department/business unit and you meet or exceed our objectives

At Anthem, we believe healthy associates are happier, more productive and more successful. That’s why we offer a range of health care options that balance attractiveness and cost – empowering you to choose the options that are most appropriate and affordable for you.

  • Medical Coverage – A Health Reimbursement Account, two Health Savings Account plans, and an HMO where available.
  • Dental Coverage – Two dental plans and a Dental HMO, where available, that offer preventive and basic services. The Enhanced Plan offers major dental procedures and orthodontia services.
  • Vision Coverage
  • Disability Benefits - Short-term disability at no cost to you if you are unable to work as a result of a covered illness or injury.
  • Employee Assistance and Work/Life Program – Comprehensive, confidential assistance for a wide array of issues that can affect the work, personal and family life of associates and their household members. Professional work/life services such as legal and financial consultations, ss well as child care and elder care referral services.
  • Programs to Improve Your Health – Onsite health services and screenings; tobacco cessation support; weight management programs; newsletters; tools; databases; health and fitness centers at many locations; and fitness club reimbursements for associates without access to an onsite fitness facility.
  • Flexible Spending Accounts – Health care and dependent care with a 10 percent company match on your contribution to the dependent care FSA.
  • Tobacco-free Workplace – All Anthem facilities are tobacco-free, because we believe in providing our associates with a safe, healthy workplace.

At Anthem, we believe making a difference in people’s lives is a practice that should extend well beyond the walls of our offices. That’s why we provide a variety of benefits designed to help associates achieve work-life balance, including:

  • Paid Time Off (PTO) - Accrues on a per-pay-period basis. You may earn 19-24 days based on your completed years of service.
  • Bereavement – Up to three paid days
  • Jury Duty Pay
  • Military Leave – Anthem pays the difference between your military pay and your base compensation for up to one year. You maintain medical, dental, vision and life insurance benefits for one year
  • Adoption Assistance – Anthem will reimburse up to $5,000 ($2,500 for part-time associates) per adoption for eligible expenses
  • Long-term Care
  • Home and Auto Insurance
  • Pet Care Discounts
  • Flexible Work Schedules
  • On-site Cafeterias
  • Scholarships
  • New Mother Rooms

The information presented here is a general summary. When a conflict exists between information provided in this general summary and terms of the plan, the plan document will prevail. Anthem reserves the right to amend or terminate its benefit plans at any time. Interns are temporary associates and therefore ineligible for many Anthem benefits.