Nurse Reviewer (Associate or Level l) Westchester, IL office (PS23751)

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.

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

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.