Medical Appeals & Grievance, RN Specialist II

🔥 0 minutes ago

🌵 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

💼 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

• Perform in-depth analysis, clinical review and resolution of provider appeals, inquiries, corrected claims, subscriber reconsiderations, member appeals and provider grievances • Identify, research, process, resolve and respond to customer inquiries through written and verbal communication • Respond daily to high-volume health insurance appeal correspondence • Analyze medical records and apply medical necessity criteria and benefit plan requirements • Maintain complete and accurate records • Meet quality, quantity, productivity, accuracy and timeliness standards required by department, regulatory and accreditation guidelines • Consult and coordinate with internal departments, external plans, providers, businesses and government agencies • Attend staff and interdepartmental meetings • Participate in continuing education and developments in medicine and managed care • Complete level-one appeals, grievances and corrected claims using benefit booklets, policies, medical criteria, claims research, contracts, fee schedules and related records • Explain contract benefits, coverage changes, eligibility, claims, programs and provider networks to customers • At higher levels, administer FEP, Blue Card Home and Blue Card Host cases; handle all levels of MAG cases; lead meetings; oversee projects; develop policies, procedures and job aids; train staff; distribute case assignments; prepare reports; analyze trends; implement process improvements and educational presentations; and provide departmental leadership

🎯 Requirements

• Associate’s Degree in a healthcare field of study or Nursing Diploma • Active, current and unrestricted Registered Nurse (RN) license to practice in Arizona or a compact state • Level 1: 1 year of experience in clinical and health insurance or another healthcare-related field • Level 2: 3 years of experience in clinical and health insurance or another healthcare-related field, plus 1 year of managed care experience • Level 3: 5 years of experience in clinical and health insurance or another healthcare-related field, plus 2 years of managed care experience • Level 4: 8 years of experience in clinical and health insurance or another healthcare-related field, plus 3 years of managed care experience and above-satisfactory managed care performance • Intermediate PC proficiency • Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones • Maintain confidentiality and privacy • Advanced clinical knowledge • Interpersonal and active listening skills • Ability to compose business correspondence • Ability to interpret and translate policies, procedures, programs and guidelines • Investigative and analytical research skills • Ability to navigate, gather, input and maintain data in multiple systems • Ability to follow and accept instruction and direction • Collaborative working relationships • Organizational and prioritization skills under time constraints • Independent judgment and problem-solving skills • Levels 3 and 4: ability to assist with training and revise or develop departmental policies, procedures and desk levels • Working knowledge of CPT, ICD-9, ICD-10, HCPCS and DRG coding is preferred • Working knowledge of McKesson InterQual criteria and medical coverage guidelines/policies is preferred • Advanced ability to interpret contract language and benefits is preferred

🏖️ Benefits

• Remote work with an onsite expectation of 0 days per week • Full-time schedule of at least 40 hours per week • Continuing education participation • Annual community service campaigns and/or projects, including CARES Club, United Way and community wellness initiatives