Benefit Review RN

Imagine360 is currently seeking a Benefit Review RN to join the team! The Benefit Review Nurse RN is responsible for providing benefit review/ utilization review and processing the independent physician review request 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 of our members.

Position Location: 100% Remote

Supervisory Responsibilities:

• None.

Duties/Responsibilities:

• Identify, collect, process, and organize data to complete the Benefit Reviews by utilization of Imagine360 Administrators approved clinical guidelines and following department policies and procedures.
• Works with case management support employees to facilitate the 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.
• Facilitates the Independent Physician review process.
• Reviews of 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.
• Communicates professionally and effectively with physicians, other healthcare professionals, peers, customers, member(s), 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.
• Maintains a current, active, and unrestricted compact Registered Nurse license as required to perform the 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 assigned by leads or supervisors.

In addition to performing standard duties, the RN engages 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 the acquired clinical data to assess for appropriateness of treatment plan based upon 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 health care team members.
• Respect the client’s right to privacy by protecting confidential information.
• Promote and participate in education and counseling to a participant based on health needs.
• Clarify any treatment that is believed to be inaccurate, non-efficacious, or contraindicated by consulting with appropriate practitioners.
• The RN Case Manager will have knowledge and practice the Core components of Case Management that include:
  • Case Management Concepts
  • Case Management PrincipleStrategies
  • Psychosocialsupport systems
  • HealthCare Managementdelivery
  • Healthcare Reimbursement
  • Vocational conceptsStrategies.

Education and Experience:

Required Education:

• Graduate of Accredited School of Nursing, College, or University

Preferred Education:

• Bachelors degree preferred.

Required Experience:

• 1+ years of Utilization Management experience
• Experience and knowledge of CPT and ICD Coding

Preferred Experience:

• Experience in utilization review services preferred.
• Experience and knowledge of CPT and ICD coding preferred.

Skills and Abilities:

• Ability to read and interpret documents such as HIPAA compliance, safety rules, operating and maintenance instructions, and policy and procedure manuals.
• Ability to draft routine reports and correspondence.
• Ability to speak effectively to members and employees.
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages.
• Ability to apply concepts of basic mathematics and fundamental accounting principles.
• Ability to apply common sense understanding to conduct instructions furnished in written, oral, or diagram form.
• Ability to deal with problems and exercise sound judgment involving several concrete variables in standardized situations.
• To perform this job successfully, an individual must have basic knowledge and skills using Microsoft Office Word, Internet software, and Database software.

Licenses or Certifications:

• Current, active, and unrestricted compact Registered Nurse license. Must maintain CEU’s as required by the State Board of Nursing. Must be willing to obtain and maintain additional license(s) as required to perform the job functions of the organization.

What can Imagine360 offer you?

• Multiple Health Plan Options, including a 100% employee paid premiums
• 100% Company paid employee premiums for Dental, Vision, STA,LTD, plus Life Insurance
• Parental Leave Policy
• 20 days PTO to start / 10 Paid Holidays
• Tuition reimbursement
• 401k Company contribution
• Professional development initiatives / continuous learning opportunities
• Opportunities to participate in and support the company’s diversity and inclusion initiatives

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Imagine360 is a health plan solution company that combines 50+ years of self-funding healthcare expertise. Over the years, we’ve helped thousands of employers save billions on healthcare. Our breakthrough total health plan solution is fixing today’s one-size-fits-none PPO insurance problems with powerful, customized, member-focused solutions.

Imagine360 is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.