Medical Appeals and Grievance Specialist II

🕒 May 26

🌵 Arizona – Remote

🌵 Arizona – Remote

⏰ Full Time

🟢 Junior

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Blue Cross Blue Shield of Arizona

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1939

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare Insurance • Insurance • Wellness

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 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. • 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.

🎯 Requirements

• 1 year' Experience in clinical and health insurance or other healthcare related field • 3 years' Experience in clinical and health insurance or other healthcare related field • 1 year' 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' 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) • 8 years' Experience in clinical and health insurance or other healthcare related field • 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) • Associate’s Degree in a healthcare field of study or Nursing Diploma (Applies to All Levels)

🏖️ Benefits

• Health insurance • 401(k) matching • Flexible work arrangements • Professional development opportunities