Nurse Reviewer (Utilization Review) Deerfield, IL (138204)
Location: Deerfield, Illinois
Posted: December 19, 2017
Reference ID: 355130413
Nurse Reviewer I
/Location: Deerfield IL/
AIM Specialty Health (AIM), a proud member of the Anthem family of companies, is a national leader in specialty benefit management. Through an innovative technology platform and steadfast commitment to excellent customer service, AIM promotes the appropriate, safe and cost effective use of clinical services including: radiology, cardiology, oncology, specialty drugs, and sleep medicine.
If you are enthusiastic about making a difference in the lives of patients, pursuing a rewarding career, and enjoying more free time with family and friends to explore your interests outside of work - consider a career as a Nurse Reviewer at our Westchester, Illinois contact center.
Nurses at AIM have a unique opportunity to balance work and family commitments by working a regular, Monday-Friday daytime schedule . We offer a comprehensive benefits package, including medical/dental/vision coverage, generous paid time off, 401(k) with company match, licensure reimbursement and much more.
Growing demand has created exceptional opportunities for nursing professionals to collaborate with AIM physicians and intake specialists in a professional, dynamic, entrepreneurial Clinical Operations environment which values a teamwork approach.
Nurse Reviewers are responsible for conducting preauthorization, 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.
Primary duties may include, but are not limited to:
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.
About AIM Specialty Health
AIM Specialty Health (AIM) is a leading specialty benefit management company with more than 20 years of experience and a growing presence in the management of radiology, cardiology, oncology, sleep medicine, and specialty pharmacy benefits. Our mission is to make healthcare services more clinically appropriate, safer and more affordable. As such, we promote the most appropriate use of specialty care services through the application of widely accepted clinical guidelines delivered via an innovative platform of technologies and services. With over 40 million members covered across 50 states, AIM ensures delivery of the right test at the right time in the right place.
AIM's services include:
Prospective clinical review of outpatient advanced imaging procedures such as CT, MRI, Nuclear Cardiology and PET Scans
Clinical review for cardiology and specialty pharmacology products and services.
Oncology Management programs leveraging AIM's proven specialty benefit platform to drive consistent and effective cancer care through services review along with management of close to 70 oncologic drugs.
Specialty Drugs programs to provide review for over 142 specialty drugs offering providers an automated drug review process through our provider friendly web portal.
Sleep Management, designed to align the diagnosis and treatment of sleep apnea against clinical guidelines, enhance member access to high value providers and ensure treatment compliance for the dispensing of supplies.
Our programs combine clinical excellence, its innovative technology and a commitment to customer service, ensuring the company's on-going leadership in the rapidly evolving healthcare environment.
AIM is certified by the National Committee for Quality Assurance (NCQA) and has received Full Accreditation for Health Utilization Management from the Utilization Review Accreditation Commission (URAC.)
A Leading Employer of Choice
Along with a dynamic, entrepreneurial work environment, AIM offers competitive compensation, a generous benefits package and the opportunities for career progression you'd expect from an industry leader.
These benefits include:
An array of Health, Dental and Vision Care Insurance plans
Term Life Insurance
Short- and Long-term Disability Insurance
401(k) Employee Savings Plan with company match
Employee Stock Purchase Plan
Paid Time Off
Tax-advantaged health care and dependent flexible spending plans
Health club reimbursement allowance
Licensure reimbursement for medical professionals
Our total rewards package is designed to attract, motivate and retain qualified individuals. Whether you are interested in medical utilization management, nursing, information technology, accounting and finance, marketing or human resources, there may be an opportunity for you at AIM. As an Equal Opportunity/Affirmative Action employer, we are committed to promoting diversity in the workplace.
Nurse Reviewer I:
Registered Nurse with a current, valid unrestricted license in the state of Illinois.
Minimum of three (3) years recent clinical nursing experience in an ambulatory or hospital setting.
Candidates should have good computer skills and solid typing speed and accuracy.
Familiarity with managed health care programs including HMO, PPO, and POS.
Familiarity with Utilization Management Guidelines preferred.
Familiarity with ICD-10 and CPT 5 coding preferred.
Previous utilization and/or quality management and/or call center experience helpful.
/ EOE.M/F/Disability/Veteran. /
Equal Employment Opportunity Statement
Anthem, Inc. will recruit, hire, train and promote persons in all job titles without regard to age, color, disability, gender (including gender identity), marital status, national origin, race, religion, sex, sexual orientation, veteran status, or other status protected by applicable law. In addition, all personnel actions such as compensation, promotion, demotion, benefits, transfers, staff reductions, terminations, reinstatement and rehire, company-sponsored training, education and tuition assistance, and social and recreational programs will be administered in accordance with the principles of equal employment opportunity.
Title: Nurse Reviewer (Utilization Review) Deerfield, IL (138204)
Requisition ID: 138204