Anthem, Inc. Nurse Reviewer, Sr in Placentia, California
SHIFT: Day Job
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.
****$5,000 Sign-On Bonus****
The Nurse Reviewer, Sr is responsible for collaborating 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. Manages reviews of all levels of complexity, only requiring guidance by more senior colleagues and/or management on new issues where standards have not been developed. Conducts 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.
Serves as a mentor and coach new and lower level associates.
Notifies ordering physician or rendering service provider office of the preauthorization determination decision.
Follows-up to obtain additional clinical information as applicable.
Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.
Requires an AS/BS in nursing from an accredited institution.
3 years of clinical nursing experience in an ambulatory or hospital setting.
3 years of prior utilization, medical management and/or quality management and/or call center experience; or any combination of education and experience, which would provide an equivalent background.
Current unrestricted RN license in applicable state(s) required.
Requires knowledge of Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans.
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. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s 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.