🌎
This job posting isn't available in all website languages

Nurse Reviewer Assoc of Nurse Reviewer I

📁
Medical
📅
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.

Previous Job Searches

Activity Feed

28928
Job shares through Anthem, Inc.
Lena Capps referred the Training Specialist - Any Anthem Location - PS23922 position. 6 days ago
Claudia Bamba referred the IT Quality Control Advisor - PS26068 position. Sep 11, 2019
Steven Myers referred the Developer II position. Sep 11, 2019
Afshan Ishtiaq referred the Program Manager - Central or Eastern Time zones-Remote Work Available-PS25904 position. Sep 03, 2019
Nagaraj Srinivasachar referred the Data Architect Exec Advisor position. Aug 14, 2019

Similar Listings

Glendale, California, United States

📁 Medical

Requisition #: PS25824

Glendale, California, United States

📁 Medical

Requisition #: PS25825

Westchester, Illinois, United States

📁 Medical

Requisition #: PS18847

Supplier Registration Process

Anthem, Inc.'s supplier registration process will automatically enter your information into our prospective supplier database.

Anthem does not do business with persons or entities identified on the General Services Administration's List of Parties Excluded from Federal Programs and the HHS\OIG List of Excluded Individuals\Entities.

Anthem, Inc. Purchase Order Terms

Anthem's standard payment terms are net 50. Payment terms will be calculated from the invoice date, which should also reflect the date goods or services were received.

Anthem also offers various discount options that provide you with the opportunity for early payment and we are also encouraging our suppliers to participate in our electronic funds transfer (EFT) method of payment. The EFT method of payment will improve the efficiency of our payment processes and ensure that you are paid properly and on time.

Anthem, Inc. Supplier Registration Process

*Please Note: To complete the supplier registration process, you will leave antheminc.com and will be directed to the Ariba Network (AN) site. Once there please click on Register as New Supplier to complete the online registration form and follow the on-screen instructions.

Supplier Registration

Anthem, Inc. utilizes the Ariba Network to determine qualified suppliers that meet Anthem’s business need. Prospective suppliers should complete Ariba’s Supplier Registration Process.*

*Please Note: To complete the supplier registration process, you will leave antheminc.com and enter the Ariba Network (AN) site. Once there, please click on 'Register as New Supplier' on the left-hand side of the screen, complete the online registration form and follow the on-screen instructions.

Anthem does not do business with persons or entities identified on the General Services Administration's List of Parties Excluded from Federal Programs and the HHS\OIG List of Excluded Individuals\Entities.

What to expect next after registration

Anthem Inc.'s Procurement department will review your registration and additional materials. If our sourcing needs align with your goods or services, an Anthem Buyer will contact you to discuss next steps and other pertinent details. If there is no current need, your information will remain in our prospective supplier database for one year for processing against future requests.

Supporting Documents

Guidelines for Prospective Suppliers (PDF)

Company Policy and Procedures (PDF)

To obtain a copy of Anthem's Supplier Travel Guidelines, please send an email to TravelPoint@anthem.com.