/This position may be located in Westchester or Deerfield, IL; or in Glendale, CA/
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.
AIM is currently seeking a Board-Certified Sleep Specialist to participate in pre-authorization and quality improvement solutions for sleep studies and high-tech diagnostic imaging. Physician Reviewers determine the medical necessity of outpatient requests using clinical appropriateness guidelines and health plan medical policy.
Successful candidates will:
Perform physician-level case review, following initial nurse review, of sleep studies and high-tech diagnostic imaging.
Determine medical necessity of requests using AIM Clinical Appropriateness Guidelines and client-specific health plan medical policy
Conduct peer-to-peer consultations with ordering physicians, physician assistants, and advanced practice nurses to provide education regarding established guidelines and accepted standards of care regarding studies and site of service.
Suggest alternative studies and sites of care to ordering providers when appropriate
Provide support and educate clinical and non-clinical staff to foster understanding of the principles associated with appropriate use of covered modalities.
Actively participate in physician team meetings.
Demonstrate and maintain knowledge of relevant policies and regulations pertaining to sleep management, and imaging modalities.
Actively participate in groups that develop, revise and enhance clinical appropriateness guidelines
Perform first level provider appeals of coverage decisions.
Obtain additional state licensure based upon state regulations and health plan needs
Adhere to all AIM Specialty Health protocols, policies, and procedures
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 sleep medicine, radiology, cardiology, oncology, 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 38 million members covered across 50 states, AIM ensures delivery of the right test at the right time in the right place.
We maintain offices in Chicago, Deerfield, Schaumburg and Westchester, IL as well as Glendale, CA.
AIM's services include:
Prospective clinical review of outpatient advanced imaging procedures such as CT, MRI, Nuclear Cardiology and PET Scans
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.
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.
Our programs combine clinical excellence, 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.)
Qualified Candidates will have:
Current unrestricted medical license(s) as a Doctor of Medicine or Doctor of Osteopathic Medicine
Current Board Certification in a Sleep Medicine subspecialty under the 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: Sleep Medicine Senior Physician Case Reviewer AIM 114774
Other Locations: IL-Westchester, CA-Glendale
Requisition ID: 114774
A little about us:
We have shared values and a similar mission.