AIM Specialty Health-Nurse Reviewer (New RN's Encouraged to Apply) Glendale

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. This is a full time position that requires in office training in Glendale, CA. This position is eligible to work from home once training is complete and requirements are met. Nurse Reviewer Associate level will consider RN's with no experience. This position is in a call-center environment and requires working a schedule Monday through Friday 9:30 am - 6:00 pm. Salary: This position has a flat starting rate. The level will be determined by the Hiring Manager based on education/ experience. - Nurse Reviewer Associate $31.21 per hour - Nurse Reviewer I $33.44 per hour The Nurse Reviewer 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.

Nurse Reviewer Associate

• Requires an AS/BS in nursing.
• Current unrestricted RN license in California
• Familiarity with managed health care programs including HMO, PPO, and POS and with ICD-9 and CPT 4 coding preferred.

Nurse Reviewer I

• Requires AS/BS in nursing; and 3 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 experience; or any combination of education and experience, which would provide an equivalent background.
• Current unrestricted RN license in California
• 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.