Benefit Review RN

Imagine360 understands We developed a self-funded health plan solution that’s fixing today’s one-size-fits-none PPO insurance problems with powerful, customized solutions. We take a different approach: putting control back in your hands and providing access to higher-quality care. For you, your employees and their families. With deep savings. And unwavering support. Imagine that.

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

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.