Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. BCBSAZ offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
This is a remote opportunity within and outside the State of Arizona.
Pay: $85,000 - $100,000
Purpose of the Job
- Responsible for utilizing clinical acumen, medical coding, and managed care expertise related to researching, resolving and recouping pre- and post-payment over utilization, fraud, waste and abuse. Works independently with senior leaders and Medical Directors. Maintains emphasis on privacy, accuracy, meeting all regulatory and compliance timelines.
Qualifications
REQUIRED QUALIFICATIONS
Required Work Experience
Experience in clinical and health insurance or other healthcare related field
Level 1 - 1 year
Level 2 - 3 years
Level 3 - 5 years
Level 4 - 8 years
Managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievances (MAG)
Level 2 - 1 years
Level 3 - 2 years
Above satisfactory job performance in the managed care environment with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievance (MAG)
Level 4 - 3 years
Required Education
- Associate’s Degree in a healthcare field of study or Nursing Diploma (Applies to All Levels)
Required Licenses
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN).
Required Certifications
PREFERRED QUALIFICATIONS
Preferred Work Experience
Experience in clinical and health insurance or other healthcare related field
Level 1 - 3 years
Level 2 - 5 years
Level 3 - 7 years
Level 4 - 9 years
Managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievances (MAG)
Level 2 - 2 years
Level 3 - 5 years
Above satisfactory job performance in the managed care environment with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management and/or Medical Appeals and Grievances (MAG)
Level 4 - 5 years
Preferred Education
- Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
- Masters Degree in Nursing or related field of study (Applies to All Levels)
Preferred Licenses
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN).
Preferred Certifications
Essential Job Functions and Responsibilities
Level I
- Perform in-depth analysis, clinical review and resolution of provider pre and post payment claims as related to medical coverage guidelines and community standards.
- Reviews and prepares internal audit cases for Medical Directors.
- Identify, research, process, resolve and respond to Sr. Medical Director inquiries primarily through written / verbal communication.
- Respond to a diverse and high volume of claims projects.
- Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of billing and charges.
- Maintain complete and accurate records per BCBSAZ policy.
- Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
- Demonstrate ability to apply plan policies and procedures effectively.
- Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of large scale projects
- Attend 1:1’s, staff and interdepartmental meetings.
- Participate in continuing education and current developments in the fields of medicine and managed care.
- Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements.
- Maintain productivity and accuracy goals based on regulatory requirements, accreditation standards, and service level agreements.
- Demonstrate ability to acquire specialized knowledge to complete all types of projects for all lines of business using appropriate benefit plan booklet, administrative guidelines and policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research and precertification research.
- Adheres to BCBSAZ brand promise of being a "Trusted Advisor" by walking in the customers shoes including processing work using the principles of easy, effective, emotional
- Maintaining Return on Investment (ROI) tracking
- Other duties as assigned (HEDIS, Quality improvement, outreach)
level II
- Ability to demonstrate specialized knowledge to do in-depth research and provide accurate written documentation
- Prepare and deliver reports and documentation for committee presentation and ad hoc reports as needed.
- Maintaining Return on Investment (ROI) tracking
level III
- Prepare and deliver reports and documentation for committee presentation and ad hoc reports as needed.
- Assist in developing new policies and procedures, desk levels, and job aids as needed.
- Assist in training new staff and provide ongoing training for existing staff as needed.
- Identify and recommend process improvements.
- Maintain Return on Investment (ROI) tracking and prepare ROI summary as directed by management
level IV
- Development and maintenance of Special Medical Projects Program Description, policies, desk level procedures and job aids
- Under minimal direction develop and maintain Return on Investment (ROI) tracking and prepare summary presentation to appropriate committees and leadership ad hoc
- Under minimal direction, prepare and deliver reports and documentation for committee presentation and ad hoc reports as needed.
- Analyze special project data and make recommendations based on trends identified.
- Take initiative to follow through on issues and opportunities for process improvements.
- Initiate, develop and implement in-service educational presentations.
- Work collaboratively with Senior Medical Directors and management, provide leadership for the department in day to day activities as well as in management’s absence.
- Maintain a working knowledge of all activities in the department and provide assistance to departmental staff and interdepartmental staff as necessary.
ALL LEVELS
- Each progressive level includes the ability to perform the essential functions of any lower levels.
- Consistently demonstrate alignment with the BCBSAZ "Living our Values" culture by participating in annual, community service campaigns and/or projects such as, CARES Club, United Way and/or community wellness initiatives (Walk for Hope, Walk to Stop Diabetes, Phoenix Heart Walk, etc.).
- The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
- Perform all other duties as assigned
Competencies
REQUIRED COMPETENCIES
Required Job Skills
- Intermediate PC proficiency (All Levels)
- Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones (All Levels)
Required Professional Competencies
- Maintain confidentiality and privacy
- Advanced clinical knowledge
- Practice interpersonal and active listening skills to achieve customer satisfaction
- Compose a variety of business correspondence
- Interpret and translate policies, procedures, programs and guidelines
- Capable of investigative and analytical research
- Navigate, gather, input and maintain data records in multiple system applications
- Follow and accept instruction and direction
- Establish and maintain working relationships in a collaborative team environment
- Organizational skills with the ability to prioritize tasks and work with multiple priorities under limited time constraints
- Independent and sound judgment with good problem solving skills
- Ability to assist in training of new and existing staff (Applies to Levels 3 and 4)
Required Leadership Experience and Competencies
- Ability to revise departmental policies and procedures and desk levels as well as develop new policies and procedures and desk levels as needed (Applies to Levels 3 and 4)
- Proven leadership and assistance through positive reinforcement of processes and company policies
- (Applies to Levels 3 and 4.)
- Independently coordinates with internal audit, corporate integrity, and other departments as needed to complete projects
PREFERRED COMPETENCIES
Preferred Job Skills
- Advanced PC proficiency
- Knowledge of Current CPT, ICD- 9, ICD-10, HCPCS, and DRG coding
- Claims processing
- End to end research
Preferred Professional Competencies
- Working knowledge of McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies
- Advanced ability to interpret contract language and benefits
Preferred Leadership Experience and Competencies
- Under minimal direction, prepare and deliver reports and documentation for committee presentation and ad hoc reports as needed.
Our Commitment
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
