/These positions may be located in our Westchester, IL; Deerfield, IL; or Glendale, CA contact centers./
Your Talent. Our Vision. AtAIM 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 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.
We are currently seekingPhysician Case Reviewersto conduct office-based pre-authorization of high-tech diagnostic imaging, cardiac testing, specialty pharmacy and sleep management services. Physician Reviewers determine the medical necessity of outpatient requests using clinical guidelines and health plan medical policy.
Successful candidates will:
Perform physician-level case review, following initial nurse review, of high-tech diagnostic imaging, modalities. Imaging modalities include CT, CTA, MRI, MRA, PET, and Nuclear Cardiology.
Determine medical necessity of requests using AIM Medical Necessity Guidelines and client-specific health plan medical policy
Conduct peer-to-peer discussions with ordering physicians, physician assistants, and nurse practitioners to provide education regarding established guidelines and accepted standards of care as they pertain to the use of diagnostic imaging studies, cardiac testing, specialty pharmacy and sleep management services.
Suggest alternatives services to ordering providers when appropriate
Document the pre-certification review in a complete, concise, and accurate manner in the pre-certification computer application
Demonstrate and maintain current knowledge of modalities and new applications of known technologies for diagnostic imaging, cardiac services, specialty pharmacy and sleep management
As necessary, assist pre-certification nurses and other staff in understanding the principles behind appropriate utilization of covered modalities.
Participate in periodic physician reviewer meetings
Demonstrate and maintain knowledge of relevant policies and regulations pertaining to utilization review of diagnostic imaging procedures, cardiac services, specialty pharmacy, radiation therapy, and sleep management.
Acquire, demonstrate, and maintain proficiency with ICD-9 and CPT coding.
Participate on committees or in work groups as needed for revision of clinical guidelines and/or serve as a subject matter expert
Perform first level provider appeals as designated by the client for adverse determinations
Obtain additional state licensure based upon business needs
Adhere to all AIM Specialty Health Management protocols, policies, and procedures
About AIM Specialty Health
AIM Specialty Health (AIM) is a leading specialty benefit management company that promotes appropriate, safe and affordable healthcare services. We are a member of the Anthem family of companies, which is recognized as one of the nation's leading health benefits companies.
AIM provides innovative clinical solutions that focus on today's most complex and costly tests and treatments in radiology, cardiology, medical and radiation oncology, specialty drugs, sleep medicine, musculoskeletal and pain management, genetic testing, palliative care, and other emerging clinical areas.
With evidence-based medicine, technology, people and processes, we support clinical appropriateness review, provider collaboration and member engagement on behalf of more than 50 health plans, 40% of the Fortune 50 Employers, and 43 million members.
Today, our team includes more than 1,100 associates and features more than 600 licensed and board-certified physicians, nurses, and other healthcare professionals who engage with more than 330,000 health care providers across the country. These healthcare providers access our solutions and specialized clinical expertise through our online ProviderPortal and experienced contact center-based teams that is enabled by our business platform.
Our pioneering spirit and dedication to improve health care continues to produce significant industry-first advancements, quality recognition achievements, and high satisfaction rates. 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.)
We maintain offices in Chicago, Deerfield, Schaumburg and Westchester, IL, as well as Glendale, CA.
To learn more, visitwww.aimspecialtyhealth.com.
Qualified Candidates will have:
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
Board Certification by American Board of Medical Specialties
Demonstrated knowledge of current practice standards in specialty
Strong oral communication and interpersonal skills
Computer literacy with the ability to learn new applications
Strong analytical skills
Ability to multi-task
Ability to work both independently and in a team environment
Ability to work in a dynamic, fast-paced environment
Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine and is a 2015 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at antheminc.com/careers. EOE. M/F/Disability/Veteran.
Title: Physician Case Reviewer AIM 120451
Other Locations: CA-Glendale, IL-Deerfield
Requisition ID: 120451
A little about us:
We have shared values and a similar mission.