Benefit Review RN

Position Location: 100% remote

About the role

The Benefit Review Nurse RN provides benefit review/utilization review and processes independent physician review requests for individuals under the group health plans administered by Imagine360 Administrators. You will utilize your nursing education, clinical and professional experience while participating in assessments, coordination, planning, monitoring, evaluation, and determining outcomes for our members. Candidates with Oncology experience are strongly preferred.

Responsibilities

• Identify, collect, process, and organize data to complete the Benefit Reviews by utilizing Imagine360 Administrators approved clinical guidelines and following department policies and procedures.
• Work with case management support employees to facilitate completion of the Benefit Review process.
• Staff medically complex cases with the Supervisor/Manager, Case Management.
• Accurate utilization and documentation in the appropriate software, including time slips in CaseTrakker, to complete and document the nurse benefit review process.
• Identify and refer cases for Physician Advisor review.
• Facilitate the Independent Physician review process.
• Review high-dollar pharmacy reports to identify appropriate referrals to Case Management or other Medical Management Services.
• Assess and review current treatment history to identify appropriate referrals to Case Management Program or other Medical Management Services.
• Communicate professionally and effectively with physicians, other healthcare professionals, peers, customers, members, and Supervisor/Manager of Case Management to complete the utilization process.
• Attend scheduled and periodic meetings, training, and other job-specific events as required, either by teleconference or onsite.
• Maintain a current license and obtain additional licenses as required to perform job functions.
• Adhere to internal Medical Management Policy and Procedures, Department of Labor, ERISA, and HIPAA regulations.
• Perform all tasks in accordance with HIPAA/PHI guidelines.
• Complete HIPAA training annually.
• Perform other duties and projects as assigned.

In addition to performing standard duties, the RN is involved in clinical decision-making and patient education. The scope of practice for nursing work includes, but is not limited to:

• Evaluating clinical data.
• Assessment and evaluation of acquired clinical data to assess the appropriateness of treatment plans based on Imagine360's clinical guidelines.
• Coordination of treatment plans, interventions, and outcomes measurement.
• Rationale for the effects of medication and treatments.
• Provide patient education and educational resources.
• Accurate reporting.
• Administration of medication and treatments.
• Contact with other healthcare team members.
• Respect the client's right to privacy by protecting confidential information.
• Promote and participate in education and counseling based on health needs.
• Clarify any treatment believed to be inaccurate, non-efficacious, or contraindicated by consulting with the appropriate practitioner.

The RN will have knowledge and practice of the core components of Case Management, which include:

• Case Management Concepts
• Case Management Principles & Strategies
• Psychosocial & Support Systems
• Healthcare Management & Delivery
• Healthcare Reimbursement
• Vocational Concepts & Strategies

Requirements

• Graduate of an Accredited School of Nursing, College, or University
• 1+ years of Utilization Management experience
• Experience and knowledge of CPT and ICD Coding

Skills

• Basic proficiency in MS Office including Outlook, Word, and Excel

Qualifications

• Active and unrestricted Compact Registered Nurse License or Active and unrestricted Nursing License

Benefits

• Multiple health plan options
• Company-paid employee premiums for disability and life insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Company-paid Short & Long-term Disability plus Life Insurance
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company's diversity and inclusion initiatives