Imagine Hiring for Benefit Review RN at Remote Full Time

Imagine360 is currently seeking a Benefit Review Nurse to join the team! The Benefit Review Nurse (RN) is responsible for completing the benefit review and specialty pharmacy review process, which includes Independent Physician review for individuals under the group health plans administered by imagine360, by utilizing their education, clinical and professional experience, and independent clinical judgement. The Benefit Review Nurse will practice within the scope of practice while participating in assessments, coordination, planning, monitoring, evaluation, and determine outcomes.

Position Location: 100% Remote

Responsibilities include but are not limited to:

• Consistently follows department Benefit Review policies and procedures to complete the review processes.
• Identify, collect, process, and organize data to complete the Benefit Reviews by utilization of imagine360 approved clinical guidelines and following department policies and procedures.
• Works with the department support employees to facilitate completion of the Benefit Review processes.
• Staffs medically complex cases with the Supervisor of Case Management, designee, or Medical Director as directed.
• Provides requested diagnosis/prognosis s and stop loss s that are received via Medical Management department requests.
• Accurate utilization and documentation in the appropriate software including time slips in CaseTrakker to complete and document the nurse benefit review processes per department policies and procedures.
• Engages in clinical consults with Managers, Senior Managers, designee, or Medical Director as directed.
• Identify and refer cases for Physician Advisor review consistent with Benefit Review policies and procedures.
• Facilitates the Independent Physician review process per Benefit Review policy and procedure.
• Reviews high dollar pharmacy s 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.
• Reviews and refers specialty medication to Pharmacy Advocacy program as indicated per the Group Plan Document and benefits.
• Completes medical necessity review for medications.
• Completes referral to specialty pharmacy vendor, when appropriate.
• Collaborates with Specialty Overlay Team for specialty medications.
• Communicates professionally and effectively as needed with physicians, healthcare professionals, peers, customers, member(s) and internal team members to complete the utilization process per department policies and procedures.
• Attend scheduled and periodic meetings, trainings, and other job specific events as required either by teleconference or on site.
• Maintains current license and obtains additional license(s) as required to perform the job functions.
• Communicate in compliance with HIPAA with members, brokers, vendors, Account Managers, and HR representatives.
• Complete and follow HIPAA training/PHI guidelines.
• Perform all tasks in accordance with HIPPA/PHI guidelines.
• Participate in quality programs per department policies and procedures as needed.
• Adhere to internal company and department policies and procedures, Department of Labor, ERISA, and HIPAA regulations.
• Perform additional duties as assigned.

Areas of Responsibility Scope of Practice:

• In addition to performing standard duties, the Registered Nurse is involved in clinical decision-making. The scope of practice includes, but is not limited to:

• • Evaluating clinical data
  • Assessment and evaluation of the acquired clinical date to assess for appropriateness of treatment based on Imagine360 clinical guidelines,
  • Coordination of treatment plans, interventions, and outcome measurement
  • Rationale for the effects of medication and treatments
  • Accurately :
    • 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 practitioner

Skills and Abilities:

• Maintain a high level of accuracy and attention to detail to perform each essential duty satisfactorily.
• Demonstrated high level of organizational skills, analytical skills, and detail oriented.
• Demonstrated ability to prioritize tasks and manage priorities to meet deadlines.

• Demonstrate a commitment to building new skills and fostering a positive work environment.
• Superior time management and multi-tasking skills
• Computer skills which include proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, as well as navigation utilizing the internet.
• Problem identification with strong problem-solving skills.

• Strong written, oral, and telephonic communication skills.
• Ability to work independently in a home office environment.

• Ability to read and interpret documents and policies and procedures.
• Ability to communicate effectively with internal and external peers and partners.
• Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, and percentages. Ability to apply concepts of basic math and fundamental accounting principles.

• Ability to maintain the confidentiality of protected health information in compliance with HIPAA regulations.

Licenses or Certification:

• An active unrestricted Registered Nurse License in eNLC compact state. Must maintain CEUs as required by applicable State Board(s) of Nursing and required certifications. Must be willing to obtain and maintain additional license as required to perform the job functions of the organization.

What can Imagine360 offer you?

• Multiple Health Plan Options, including a 100% Employer Paid Benefit Options
• 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.

**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**