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Case Reviewer - NP/PA - Orthopedic Surgery/Joints


  • California, California
  • National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint



AIM Specialty Health

Case Reviewer - NP/PA

Orthopedic Surgery Review (Joints)

AIM Specialty Health is a benefit-management leader in Illinois and a proud member of Elevance Health's family of companies. Our platform delivers significant cost-of-care savings across an expanding set of clinical domains, including radiology, cardiology and oncology. 

Job Summary:

Responsible for conducting pre-authorization, out of network and appropriateness of tests by utilizing appropriate policies, clinical and department guidelines. Collaborates with healthcare providers to promote the most appropriate, highest quality and effective use of required tests, medications, interventional procedures and surgeries to ensure quality member outcomes, and to optimize member benefits.

Primary duties may include, but are not limited to:

  • Receives pre-authorization requests from front-line intake and nurse reviewers.
  • Conducts initial medical necessity clinical screenings.
  • Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review by a Medical Director.
  • Works closely with Medical Directors to review and make recommendations regarding medical necessity of requested tests, medications, interventional procedures and surgeries.
  • Documents the results of the initial clinical review and determination in the pre-certification system.
  • Conducts initial medical necessity review of out of network pre-authorization requests for services.
  • Conducts review of grievance and appeals requests to provide to Medical Directors.

Desired Skills and Abilities:

  • Requires MA/MS from an ARC-PA (Accreditation Review Commission for the Physician Assistant) accredited program or an ACEN/CCNE (Accreditation Commission for Education in Nursing or Commission on Collegiate Nursing Education) accredited program.
  • Minimum of 3 years of clinical experience is also required.
  • Certified and current, active, unrestricted license as a Physician Assistant or APRN (Advanced Practice Registered Nurse) in applicable state(s) required.
  • AAPA (American Academy of PAs) and applicable state license required for Physician Assistants.  
  • APRN and applicable state license(s) required for Nurse Practitioners.
  • Expereince in clinical Orthopedic Surgery strongly preferred.

For candidates working in person or remotely in the below locations, the salary* range for this specific position is $42.87 to $85.44 hourly.

Locations:  California; Colorado; Nevada; Washington State; Jersey City, NJ; New York City, NY; Ithaca, NY and Westchester County, NY

In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the company.  The company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws .

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

Please be advised that Elevance Health only accepts resumes from agencies that have a signed agreement with Elevance Health. Accordingly, Elevance Health is not obligated to pay referral fees to any agency that is not a party to an agreement with Elevance Health. Thus, any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.

Be part of an Extraordinary Team

Elevance Health is a health company dedicated to improving lives and communities – and making healthcare simpler. Previously known as Anthem, Inc., we have evolved into a company focused on whole health and updated our name to better reflect the direction the company is heading.

We are looking for leaders at all levels of the organization who are passionate about making an impact on our members and the communities we serve. You will thrive in a complex and collaborative environment where you take action and ownership to solve problems and lead change. Do you want to be part of a larger purpose and an evolving, high-performance culture that empowers you to make an impact?

We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

The health of our associates and communities is a top priority for Elevance Health. We require all new candidates to become vaccinated against COVID-19. If you are not vaccinated, your offer will be rescinded unless you provide – and Elevance Health approves – a valid religious or medical explanation as to why you are not able to get vaccinated that Elevance Health is able to reasonably accommodate. Elevance Health will also follow all relevant federal, state and local laws.

Elevance Health has been named as a Fortune Great Place To Work in 2021, is ranked as one of the 2021 World’s Most Admired Companies among health insurers by Fortune magazine, and a Top 20 Fortune 500 Companies on Diversity and Inclusion. To learn more about our company and apply, please visit us at Elevance Health is an Equal Employment Opportunity employer and all qualified applicants will receive consideration for employment without regard to age, citizenship status, color, creed, disability, ethnicity, genetic information, gender (including gender identity and gender expression), marital status, national origin, race, religion, sex, sexual orientation, veteran status or any other status or condition protected by applicable federal, state, or local laws. Applicants who require accommodation to participate in the job application process may contact for assistance.

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