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Registered Nurse - Utilization Review Call Center - Westchester, IL in Westchester, IL at Anthem, Inc.

Date Posted: 12/5/2018

Job Snapshot

Job Description

The use of this job is limited to the AIM business unit. If you believe this to be the best match for your position, please consult with your Human Resources partner prior to using this job (HRBP should work with Compensation). Responsible for conducting preauthorization, out of network and appropriateness of treatment reviews for diagnostic imaging services by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers, and members to promote the most appropriate, highest quality and effective use of diagnostic imaging to ensure quality member outcomes, and to optimize member benefits. Works on reviews that are routine having limited or no previous medical review experience requiring guidance by more senior colleagues and/or management. Partners with more senior colleagues to complete non-routine reviews. Through work experience and mentoring learns to conduct medical necessity clinical screenings of preauthorization request to assess assessing the medical necessity of diagnostic imaging procedures, out of network services, and appropriateness of treatment. Primary duties may include, but are not limited to: Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review. Conducts initial medical necessity review of exception 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. Follows-up to obtain additional clinical information. Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics. Requires AS/BS in nursing; 3 years of clinical nursing experience in an ambulatory or hospital setting; or any combination of education and experience, which would provide an equivalent background. Current unrestricted RN license in applicable state(s) required. Requires familiarity with Utilization Management Guidelines, ICD-9 and CPT-4 coding, and managed health care including HMO, PO and POS plans. Previous utilization and/or quality management and/or call center experience preferred.
AnEqualOpportunityEmployer/Disability/Veteran