Nurse Reviewer (Associate or Level I) - Illinois Required

Description SHIFT: Day JobSCHEDULE: Full-timeYour 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.Nurse Reviewers ( Associate or Level I) 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. Whether you are newly licensed RN, or have many years of RN experience, we want to consider you! We currently have multiple new spots to fill.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 until further notice. Once we go back to standard operations, these positions will be located in Westchester, IL. The schedule for this position is Monday - Friday, 9:30am to 6:00 pm CST.

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.

Qualifications Nurse Reviewer (Associate or Level I) SHARED qualifications:Current active, valid unrestricted RN license in the state of IL;

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 Associate specific qualifications:

Graduate of an accredited school of nursing;

Customer service experience is preferred;

Quality management and/or call center experience is a plus;

Any experience in clinical nursing experience is a plus.

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.

All perspective candidates should have an access to the Internet with the following characteristics:Minimum download speed of 10 megabytes per second (mbps) is required

Minimum upload speed of 3 megabytes per second (mbps) is required

Next available class date is: February 15

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2019 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.REQNUMBER: PS43092-US