Medical Appeals and Grievance (MAG) Specialist II

Blue Cross Blue Shield of Arizona•Phoenix, AZ

2d•Remote

About The Position

Blue Cross Blue Shield of Arizona (AZ Blue), an awarded Healthiest Employer, aims to inspire health and make it easy by offering a variety of health insurance products and services. AZ Blue provides information and tools to help individuals make better health decisions. The company operates with a hybrid workforce strategy called Workability, offering flexibility in how and where employees work, with positions classified as hybrid, onsite, or remote. This specific position is remote within the state of Arizona, requiring residency and work to be performed within AZ. The purpose of this role is to utilize clinical acumen and managed care expertise to research, resolve, and respond to requests for member and provider appeals, grievances, reconsiderations, and corrected claims across all lines of business, with a strong emphasis on privacy, accuracy, and adherence to all regulatory and compliance timelines.

Requirements

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)
Associate’s Degree in a healthcare field of study or Nursing Diploma
Active, current, and unrestricted license to practice in the State of Arizona or a compact state as a Registered Nurse (RN)
Intermediate PC proficiency
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones
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

Nice To Haves

5 years' Experience in clinical and health insurance or other healthcare related field
Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies
Advanced ability to interpret contract language and benefits
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)
Bachelor's Degree in Nursing or related field of study
Advanced PC proficiency
Knowledge of Current CPT, ICD- 9, ICD-10, HCPCS, and DRG coding

Responsibilities

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 organization’s 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 “Trusted Advisor” by walking in the customers shoes including processing work using the principles of easy, effective, emotional
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
Demonstrate specialized knowledge to perform reviews for local lines of business, Blue Card Home member appeals and grievances, and Blue Card Host provider grievances
Support FEP for member reconsiderations, provider appeals, corrected claims and inquiries
Perform all other duties as assigned