DescriptionSHIFT: Day Job
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.
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, must reside within California
Schedule: Monday - Friday, 9:30 am to 6:00 pm PST.
Target Start Date: April 26th,2021
• $31.21 per hour for the Associate level
• $33.86 per hour for the Reviewer I
Please note that the level offered is determined by the Hiring Manager based on experience.
Nurse Reviewer (Associate or Level I)
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 (Associate or Level I) SHARED qualifications:
• Current active, valid unrestricted RN license in the state of California is required.
• 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
Access to the Internet with the following characteristics:
• Minimum download speed of 10 megabytes per second (mbps) / upload speed of 3 megabytes per second (mbps) is required
As one of America’s largest health benefits companies, we at Anthem have a profound appreciation for service. Our organization proudly supports our Nation’s active, reserve, and veteran military service members and their spouses.
This is an exciting opportunity to advance your life and career, while still protecting and serving others. Come see for yourself why Anthem is recognized as a Top Employer by GI Jobs and among the “Best of the Best: Top Veteran Friendly Companies” by US Veterans Magazine.
Who We Are Looking For
Anthem, Inc. is seeking military veterans across the country who bring a deeply rooted skillset that includes team-oriented approaches to problem-solving, demonstrations of leadership and an overall commitment to the mission of the organization. If you are a military veteran or military veteran spouse, Anthem, Inc. is looking to hire you.
Join Anthem's Military and Veteran Talent Network: https://anthemcareers.ttcportals.com/pages/military
Should I Apply?
Are you a transitioning member of the military or a military veteran who is looking for a civilian career that provides opportunities for growth and career advancement? Anthem, Inc. is currently looking for job seekers with Operations experience. If you are interested in a career in one of these fields, check out our current open positions to the right for more information and to apply today!
What Happens After I Apply?
Once you click ‘Apply Now’ on an Anthem, Inc. job posting, you will be re-directed to fill out an application on Anthem's career page. In order to be considered for next steps, please complete the application on Anthem's career page and make sure you have an updated resume uploaded to your RecruitMilitary profile. Once Anthem, Inc. reviews your resume and profile, a recruiter will reach out to provide you with more information and to schedule you for an interview.
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Anthem, Inc. | , California
Anthem, Inc. | Fresno, California