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Anthem, Inc. Nurse Reviewer (Associate or Level I) - Remote - Sign-On Bonus in Montebello, California


SHIFT: Day Job

SCHEDULE: Full-time

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.

****$5,000 Sign-On Bonus****

The Nurse Reviewer Associate or Nurse Reviewer I is 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:

  • 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 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.



Nurse Reviewer (Associate or Level I) SHARED qualifications:

  • Current active, valid unrestricted RN license 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 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 Qualifications:

  • Requires AS/BS in nursing from an accredited institution.

  • 3 years of clinical nursing experience in an ambulatory or hospital setting or 1 year of prior utilization management, medical management and/or quality management, and/or call center experience; or any combination of education and experience, which would provide an equivalent background.

  • Current valid and 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.

    We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. Anthem, Inc. has been named as a Fortune 100 Best Companies to Work For®, is ranked as one of the 2020 World’s Most Admired Companies among health insurers by Fortune magazine, and a 2020 America’s Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.

    REQNUMBER: PS54877