Registered Nurse-Medical Appeals and Grievance Specialist-prior...
Work with a team of bright and motivated people as a Registered Nurse-medical Appeals And Grievance Specialist-prior...! The role is situated in Remote, offering a fantastic work environment. This position requires a strong and diverse skillset in relevant areas to drive success. We believe in rewarding talent. The total rewards package for this role includes a competitive salary. Â Â Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue 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.
The remote work... opportunity requires residency, and work to be performed within the State of Arizona.
Purpose of the job
Responsible for utilizing clinical acumen and managed care expertise related to researching, resolving and responding to requests for member and provider appeals, grievances, reconsiderations and corrected claims for all lines of business with emphasis on privacy, accuracy, meeting all regulatory and compliance timelines.
REQUIRED QUALIFICATIONS
Required Work Experience
Level 1 1 year Experience in clinical and health insurance or other healthcare related field
Level 2 3 years Experience in clinical and health insurance or other healthcare related field
Level 3 5 years Experience in clinical and health insurance or other healthcare related field
Level 4 8 years Experience in clinical and health insurance or other healthcare related field
1 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
3 years Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Required Education
 AssociateÂs 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) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW. (All Levels)
Required Certifications
 N/A
PREFERRED QUALIFICATIONS
Preferred Work Experience
Level 1 3 years Experience in clinical and health insurance or other healthcare related field
Level 2 5 years Experience in clinical and health insurance or other healthcare related field
Level 3 7 years Experience in clinical and health insurance or other healthcare related field
Level 4 9 years Experience in clinical and health insurance or other healthcare related field
2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Preferred Education
 Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
Preferred Licenses
 N/A
Preferred Certifications
 N/A
ESSENTIAL job functions AND RESPONSIBILITIES
Level I
 Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
 Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
 Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
 Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
 Maintain complete and accurate records per department policy.
 Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
 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 customer inquiries.
 Attend 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 level one appeals, grievances and corrected claims for local 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.
 Articulate to customers a variety of information about the organizationÂs services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, and provider networks.
 Adheres to BCBSAZ brand promise of being a ÂTrusted Advisor by walking in the customers shoes including processing work using the principles of easy, effective, emotional
level II
 Ability to demonstrate specialized knowledge to administer Federal Employee Program (FEP)inquiries, appeals, grievances and sub-reconsiderations using appropriate service benefit plan provisions, and internal policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research, and precertification research.
 Ability to demonstrate specialized knowledge to perform reviews for local lines of business, Blue Card Home member appeals and grievances, and Blue Card Host provider grievances. MAG Clinicians also support FEP for member reconsiderations, provider appeals, corrected claims and inquiries.
level III
 Ability to demonstrate specialized knowledge to complete all Levels of Medical Appeals and Grievance (MAG) cases (Initial internal, voluntary internal and external review appeals and grievances).
 Under minimal direction, lead interdepartmental meetings and oversee special projects as assigned.
 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.
 Assist in distribution of staff Flow Manager case assignments.
 Identify and recommend process improvements.
level IV
 Assist in distribution of staff case assignments.
 Under minimal direction, prepare reports and documentation for committee presentation and ad hoc reports as needed.
 Analyze appeals and grievances 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 management and provide leadership for the department in day to day activities as well as in managementÂs absence.
 Maintain a working knowledge of all activities in the department and provide assistance to departmental staff and interdepartmental staff as necessary.
 Consistently demonstrate alignment with the BCBSAZ ÂLiving 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).
ALL LEVELS
 Each progressive level includes the ability to perform the essential functions of any lower levels.
 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.)
PREFERRED COMPETENCIES
Preferred Job Skills
 Advanced PC proficiency
 Knowledge of Current CPT, ICD- 9, ICD-10, HCPCS, and DRG coding
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
 N/A
Our Commitment
AZ Blue 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 Apply Job! For more such jobs please click here! Submit Your ApplicationSeize this opportunity to make a significant impact. Apply now and take the first step towards a rewarding new role.
Apply Now
The remote work... opportunity requires residency, and work to be performed within the State of Arizona.
Purpose of the job
Responsible for utilizing clinical acumen and managed care expertise related to researching, resolving and responding to requests for member and provider appeals, grievances, reconsiderations and corrected claims for all lines of business with emphasis on privacy, accuracy, meeting all regulatory and compliance timelines.
REQUIRED QUALIFICATIONS
Required Work Experience
Level 1 1 year Experience in clinical and health insurance or other healthcare related field
Level 2 3 years Experience in clinical and health insurance or other healthcare related field
Level 3 5 years Experience in clinical and health insurance or other healthcare related field
Level 4 8 years Experience in clinical and health insurance or other healthcare related field
1 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
3 years Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Required Education
 AssociateÂs 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) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW. (All Levels)
Required Certifications
 N/A
PREFERRED QUALIFICATIONS
Preferred Work Experience
Level 1 3 years Experience in clinical and health insurance or other healthcare related field
Level 2 5 years Experience in clinical and health insurance or other healthcare related field
Level 3 7 years Experience in clinical and health insurance or other healthcare related field
Level 4 9 years Experience in clinical and health insurance or other healthcare related field
2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
5 years Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
Preferred Education
 Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
Preferred Licenses
 N/A
Preferred Certifications
 N/A
ESSENTIAL job functions AND RESPONSIBILITIES
Level I
 Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
 Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
 Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
 Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
 Maintain complete and accurate records per department policy.
 Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines and required by State, Federal and other accrediting organizations.
 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 customer inquiries.
 Attend 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 level one appeals, grievances and corrected claims for local 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.
 Articulate to customers a variety of information about the organizationÂs services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, and provider networks.
 Adheres to BCBSAZ brand promise of being a ÂTrusted Advisor by walking in the customers shoes including processing work using the principles of easy, effective, emotional
level II
 Ability to demonstrate specialized knowledge to administer Federal Employee Program (FEP)inquiries, appeals, grievances and sub-reconsiderations using appropriate service benefit plan provisions, and internal policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research, and precertification research.
 Ability to demonstrate specialized knowledge to perform reviews for local lines of business, Blue Card Home member appeals and grievances, and Blue Card Host provider grievances. MAG Clinicians also support FEP for member reconsiderations, provider appeals, corrected claims and inquiries.
level III
 Ability to demonstrate specialized knowledge to complete all Levels of Medical Appeals and Grievance (MAG) cases (Initial internal, voluntary internal and external review appeals and grievances).
 Under minimal direction, lead interdepartmental meetings and oversee special projects as assigned.
 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.
 Assist in distribution of staff Flow Manager case assignments.
 Identify and recommend process improvements.
level IV
 Assist in distribution of staff case assignments.
 Under minimal direction, prepare reports and documentation for committee presentation and ad hoc reports as needed.
 Analyze appeals and grievances 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 management and provide leadership for the department in day to day activities as well as in managementÂs absence.
 Maintain a working knowledge of all activities in the department and provide assistance to departmental staff and interdepartmental staff as necessary.
 Consistently demonstrate alignment with the BCBSAZ ÂLiving 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).
ALL LEVELS
 Each progressive level includes the ability to perform the essential functions of any lower levels.
 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.)
PREFERRED COMPETENCIES
Preferred Job Skills
 Advanced PC proficiency
 Knowledge of Current CPT, ICD- 9, ICD-10, HCPCS, and DRG coding
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
 N/A
Our Commitment
AZ Blue 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 Apply Job! For more such jobs please click here! Submit Your ApplicationSeize this opportunity to make a significant impact. Apply now and take the first step towards a rewarding new role.
Apply Now