Medication Benefit Review Nurse – Gene & Cell Therapy

Imagine360 is seeking a Medication Benefit Review Nurse – Gene & Cell Therapy to join the team!  The Medication Benefit Review Nurse – Gene & Cell Therapy (CGT) is responsible for conducting comprehensive utilization reviews, clinical benefit determinations in alignment with plan language, and clinical assessments for medications and treatments, specifically high-cost, gene and cell therapies (CGT). This role requires advanced critical thinking, mastery of clinical evidence evaluation, and application of P&T committee guidelines, vendor-supplied criteria, or client-preferred clinical guidelines to ensure consistent, accurate, and compliant determinations. In addition to gene and cell therapy reviews, the nurse also performs standard medication benefit reviews, including coordination of specialty medications and traditional benefit determinations. The nurse collaborates across UM, Claims, Care Navigation, and external partners and practices within the licensed scope to support safe, high-quality review processes.

Position Location: 100% remote

Responsibilities include but are not limited to:

Medication and Treatment Review Functions (CGT and Standard)

• Identify, collect, process, and manage data to complete reviews for medical necessity per Medical Management approved clinical guidelines.
• Perform medical necessity reviews for gene and cell therapies using evidence based guidelines, FDA labeling, clinical trial data, and national standards (e.g., NCCN)
• Conduct standard medication benefit reviews of medical necessity, including:
• Traditional clinical benefit determinations including but not limited to medical necessity and experimental/investigational evaluations in alignment with plan language.
• Specialty medication coordination
• Application of standard, evidence-based clinical guidelines for non-CGT treatments and therapies
• Review of precertification/retrospective requests for medical necessity.
• Evaluate clinical records for all medication types (CGT and non‑CGT): prior therapies, comorbidities, treatment plans, dosing, and safety considerations.
• Identify discrepancies, contraindications, or missing documentation and request supplemental information.
• Provide clinical assessments for all high cost or complex medication cases.

Program Coordination (CGT and Standard):

• Complete eligibility assessments, medical necessity reviews, and coordination steps for all medication review types.
• Collaborate with Care Navigation and internal teams to support scheduling needs, documentation requirements, and clarification of treatment plans.
• Serve as a clinical resource for medication review questions across internal and external stakeholders.

Regulatory and Quality Compliance:

• Ensure compliance with URAC, ERISA, state specific regulations, and organizational guidelines across all review categories.
• Participate in quality review activities to ensure consistency and accuracy in clinical decision-making.
• Accurately document all reviews in UM systems, including required time slips, and maintain strict HIPAA/PHI adherence.

Collaboration and Escalation:

• Consult with Team Leads, Supervisors, Physician Advisors, and Independent Review Organizations (IROs) for complex cases.
• Participate in peer-to-peer/provider discussions when required.
• Support appeals process with detailed clinical review and documentation.

Operational Excellence:

• Contribute to process improvement initiatives for both CGT and standard medication review workflows.
• Participate in pilot programs, training, and cross functional initiatives.
• Maintain awareness of emerging therapies, evolving guidelines, and changes to clinical review standards.

Scope of Practice – Specialized CGT Components:

The Licensed Nurse participates in elevated CGT specific clinical assessment, including:

• Applying therapy specific eligibility criteria (e.g., prior therapies, clinical severity indicators, transplant candidacy).
• Ensuring patient safety considerations are addressed (e.g., bridging therapy, apheresis,, readiness, preconditioning requirements).
• Interpreting high complexity laboratory and clinical findings relevant to CGT.

Overview Areas of Responsibility - Scope of Practice:

In addition to performing standard duties, the Licensed 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 data to assess appropriateness of treatment based on Imagine360 clinical guidelines.
• 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 an appropriate practitioner.

Required Experience/Education:

Required Education, Licensures/Certifications, and Experience:

• Education - Nursing degree from an accredited college, university, institution, or nursing school.
• Licensure - Active, unrestricted registered nursing in an eNLC compact state.
• Experience - Minimum 1 year Utilization Review/Benefit Review or transferable clinical experience.

Preferred Education and Experience:

• Education - Bachelor's degree in nursing preferred but not required
• Experience:
  • Preferred experience managing patients with conditions/treatments in oncology, hematology, transplant medicine, infusion therapy, or rare genetic disorders – all age groups
• Familiarity with:
  • NCCN, MCG, or other specialty framework guidelines
  • FDA-authorized REMS programs
  • P&T committees
  • Experience with specialty medication reviews or high-cost therapy adjudication, such as chemotherapy and specialty medications.
  • Experience working in a URAC-accredited program
  • Experience working within an insurance agency or TPA experience specializing in employee benefits and self-funded medical plans.

Skills and Abilities:

• Ability to work independently in a home office environment.
• Computer skills which include proficiency in Microsoft Outlook, Word, Excel, and PowerPoint, as well as navigation utilizing the internet.
• Ability to resolve problems independently and demonstrate ability to multi-task.
• Strong written, oral, and telephonic communication skills.
• Strong presentation skills.
• Strong competency in reviewing complex medical records for advanced therapies and standard medications.
• Ability to interpret and apply CGT related and standard clinical guidelines.
• High proficiency in critical analysis, clinical reasoning, and risk identification.
• Excellent written, verbal, and telephonic communication skills.
• Ability to work independently in an intensive, fast paced environment with minimal supervision.
• Strong proficiency using Microsoft Office Suite and UM platforms.
• Ability to manage sensitive, high complexity cases requiring efficient turnaround times.
• Strong organizational, prioritization, and multitasking skills.
• Ability to stay organized and interact well with others in any situation.
• Ability to collaborate effectively across multidisciplinary teams.
• Attend and participate in team meetings, trainings, and other job specific events as required.
• Communicate professionally and effectively with brokers, vendors, Relationship Managers, HR representatives, and stop‑loss partners (in compliance with HIPAA).
• Adhere to internal regulations regarding Department of Labor, HIPAA, ERISA, and all department/company policies and procedures.
• Complete HIPAA and URAC training annually.
• Perform all tasks in accordance with HIPAA/PHI guidelines.
• Appropriately escalate difficult issues.
• Complete duties in accordance with scope of licensure and certifications held or requested.
• Perform other duties and projects as assigned

License and Certifications:

• An active, current, unrestricted Licensed Nurse 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 licenses as required to perform the job functions of the organization.
• CGT-specific training highly encouraged

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

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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**