Location
, CA, United States
Posted on
Feb 26, 2022
Profile
Description SHIFT: Day JobSCHEDULE: Full-timeBe part of an extraordinary teamnWe 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?nThe 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).n**********$5,000 Sign-On Bonus**********nu00a0nTheu00a0Nurse Reviewer Iu00a0is 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.nPrimary duties may include, but are not limited to:nntReceives pre-authorization requests from front-line intakentConducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.ntConducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.ntNotifies ordering physician or rendering service provider office of the preauthorization determination decision.ntFollows-up to obtain additional clinical information.ntEnsures proper documentation, provider communication, and telephone service per department standards and performance metrics.nnu00a0nTheu00a0Nurse Reviewer Associateu00a0are 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.nPrimary duties may include, but are not limited to:nntReceives pre-authorization requests from front-line intakentConducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.ntConducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.ntNotifies ordering physician or rendering service provider office of the preauthorization determination decision.ntFollows-up to obtain additional clinical information.ntEnsures proper documentation, provider communication, and telephone service per department standards and performance metrics.nnQualifications 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.u00a0nu00a0nLocation: Work from home in CalifornianSchedule: Monday - Friday, 9:30 am to 6:00 pm u00a0PSTnnInternet Requirement: Minimum download speed of 20 megabytes per second (mbps) / upload speed of 5 megabytes per second (mbps)u00a0nu00a0nNurse Reviewer Associate primary requirements:u00a0nntCurrent active, valid, unrestricted California RN license.ntKnowledge of managed healthcare programs.nnnNurse Reviewer Associate preferred requirements: u00a0nntCustomer service experience is preferred.ntQuality management and/or call center experience is a plusu00a0ntAny experience in clinical nursing experience is a plusu00a0ntHMO, PPO, and POS are preferred.ntFamiliarity with Utilization Management Guidelines preferred.ntFamiliarity with ICD-10 and CPT 4 coding preferred.nnu00a0nNurse Reviewer I prmiary requirements:nntRequires AS/BS in nursing from an accredited institution.ntCurrent valid and unrestricted California RN license in applicable state(s) required.nt3 years of clinical nursing experience in an ambulatory or hospital setting or 1 year of prior utilization management, medical management and/or quality management, and/or call center experiencentRequires familiarity with Utilization Management Guidelines, ICD-10 and CPT-4 coding, and managed health care including HMO, PPO and POS plans.nnNurse Reviewer I preferred requirements: u00a0nntPrevious utilization and/or quality management and/or call center experience preferred.nnu00a0nNurse Reviewer (Associate or Level I) Soft Skills:nntCandidates must have good computer skills and solid typing speed and accuracy.nnnWe 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.nnThe 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 u2013 and Anthem approves u2013 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.nn**MEMBERS ONLY**SIGN UP NOW***. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 Worldu2019s 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 **** for assistance.
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