Initial Clinical Reviewer

🔥 11 minutes ago

🌵 Arizona – Remote

🌵 Arizona – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔍🏥 Medical Reviewer

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Blue Cross Blue Shield of Arizona

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1939

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

Blue Cross Blue Shield of Arizona is a health insurance provider offering a variety of health plans tailored to individuals, families, employers, and Medicare recipients. With a commitment to improving healthcare access and community health, AZ Blue provides self-insured and ACA-compliant health plans, including Medicare Advantage and Medicaid options. The organization focuses on connecting members with care through its extensive network, aiming for better health outcomes and community support.

📋 Description

• Responsible for identifying, researching, processing, resolving, and responding to inquiries from internal and external customers with emphasis on excellence, privacy, compliance and versatility within the health insurance industry. • Answer a diverse and high volume of health insurance related customer calls or correspondence on a daily basis. • Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit 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. • Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc. • Demonstrate ability to apply plan policies and procedures effectively. • When indicated to assist with team/project functions: Collaborate with team to distribute workload/work tasks; Monitor and report team tasks; Communicate team issues and opportunities for improvement to supervisor/manager; Support/mentor team members. • 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.

🎯 Requirements

• 2 years of experience in clinical field of practice, health insurance, or other health care related field • Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program • Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN, OR an active, current, and unrestricted license to practice in the State of Arizona as an LPN. • Intermediate PC proficiency • Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones

🏖️ Benefits

• Health insurance • Flexible work arrangements