Benefit Review RN

Imagine360 is 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 Responsibilities include but are not limited to: 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 the case management support employees to facilitate completion of the Benefit Review process. Staffs 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 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 current license and obtains additional license as required in order 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, 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 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- effacious , or contraindicated by consulting with appropriate practitioner . The RN will have knowledge and practices the Core components of Case Management that include: Case Management Concepts Case Management Principle & Strategies Psychosocial & support systems HealthCare Management & delivery Healthcare Reimbursement Vocational concepts & Strategies. Required Experience/Education: Graduate of Accredited School of Nursing, College, or University 1+ years of Utilization Management experience Experience and knowledge of CPT and ICD Coding Skills and Abilities: Basic proficiency in MS Office including Outlook, Word, and Excel License and Certifications: Active and unrestricted Compact Registered Nurse License or Active and unrestricted Nursing License What can Imagine360 offer you? 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 Want to see our latest job opportunities? Follow us on LinkedIn 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. **RECRUITMENT AGENCIES PLEASE NOTE: Imagine360 will only accept applications from agencies/business partners that have been invited to work on a specific role. Candidate Resumes/ CV's submitted without permission or directly to Hiring Managers will be considered unsolicited and no fee will be payable. Thank you for your cooperation**