Nurse Reviewer Associate or Nurse Reviewer I

Job Description

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.

If you are enthusiastic about making a difference in the lives of patients, pursuing a rewarding career, and enjoying more free time with family and friends to explore your interests outside of work - consider a career as a Nurse Reviewer at our Glendale, CA, contact center.

Registered Nurse - Utilization Review - Glendale, CA

Nurse Reviewer I and Nurse Reviewer Associate are responsible for conducting pre-authorization, out of network and appropriateness of treatment reviews for diagnostic imaging and other services by utilizing appropriate policies, clinical and department guidelines. They collaborate 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.

If you just graduated and have your RN License OR if you are a RN with many years of experience, we want to consider you! These are in-office positions located in Glendale, CA, with a set schedule of Monday - Friday, 9:30am to 6:00 pm.

Primary duties may include, but are not limited to:

• Receives pre-authorization 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 pre-authorization requests for services requested outside of the client health plan network
• Notifies ordering physician or rendering service provider office of the pre-authorization determination decision
• Documents the results of the initial clinical review and determination in the pre-certification computer system
• Maintains confidentiality of patient and provider specific information
• Develops telephone service standards to meet departmental performance metrics

Nurse Reviewer I & Nurse Reviewer Associate SHARED qualifications:

• Registered Nurse with a current, valid unrestricted license in the State of California
• Candidates must have good computer skills and solid typing speed and accuracy
• Knowledge of managed healthcare programs - HMO, PPO, and POS are preferred
• Familiarity with Utilization Management Guidelines preferred
• Familiarity with ICD-9 and CPT 4 coding preferred

Nurse Reviewer I specific qualifications:

• 3 + years recent clinical nursing experience in an ambulatory or hospital setting
• Previous utilization and/or quality management and/or call center experience is helpful

Nurse Reviewer Associate specific qualifications:

Graduate of an accredited school of nursing

• Any experience in clinical nursing experience is a plus
• Customer service experience is preferred
• Quality management and/or call center experience is a plus

AIM- A Leading Employer of Choice, Benefits at a Glance

Along with a dynamic, entrepreneurial work environment, AIM offers competitive compensation, a generous benefits package and the opportunities for career progression you'd expect from an industry leader.

These benefits include:

An array of Health, Dental and Vision Care Insurance plans

• Term Life Insurance
• Short- and Long-term Disability Insurance
• 401(k) Employee Savings Plan with company match
• Employee Stock Purchase Plan
• Paid Time Off
• Tuition Reimbursement
• Tax-advantaged health care and dependent flexible spending plans
• Health club reimbursement allowance
• Licensure reimbursement for medical professionals

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2017 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers . EOE. M/F/Disability/Veteran.