Anthem, Inc. Nurse Reviewer (Associate or Level I) in Modesto, California
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AIM Specialty Health is a benefit-management leader in Illinois and a proud member of Anthem's family of companies. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology.
Nurse Reviewers 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. 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. Location: Work from home Schedule: Monday - Friday, 9:30 am to 6:00 pm
Internet Requirement: Minimum download speed of 20 megabytes per second (mbps) / upload speed of 5 megabytes per second (mbps) 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
Location: Work from home
Schedule: Monday - Friday, 9:30 am to 6:00 pm
Internet Requirement: Minimum download speed of 20 megabytes per second (mbps) / upload speed of 5 megabytes per second (mbps)
Nurse Reviewer Associate Requirements:
- Current active, valid, unrestricted RN license.
Nurse Reviewer Associate Preferred Qualifications:
Customer service experience is preferred.
Quality management and/or call center experience is a plus
Any experience in clinical nursing experience is a plus
HMO, PPO, and POS are preferred.
Familiarity with Utilization Management Guidelines preferred.
Familiarity with ICD-10 and CPT 4 coding preferred.
Nurse Reviewer I Requirements:
Requires AS/BS in nursing from an accredited institution.
Current valid and unrestricted RN license in applicable state(s) required.
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
Nurse Reviewer I Preferred Qualifications:
- Previous utilization and/or quality management and/or call center experience preferred.
Nurse Reviewer (Associate or Level I) Soft Skills:
Candidates must have good computer skills and solid typing speed and accuracy.
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. The health of our associates and communities is a top priority for Anthem. We require all new candidates to become vaccinated against Covid-19. All offers of employment are conditioned on completion of a background check, including COVID-19 vaccination verification. If you are not vaccinated, your offer will be rescinded unless you provide – and Anthem approves – 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. Anthem, Inc. has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s 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 firstname.lastname@example.org for assistance.