Medical Appeals/Grievance Specialist II - Registered Nurse (REMOTE - AZ)

Blue Cross Blue Shield of Arizona•Phoenix, AZ

2d•Remote

About The Position

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. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This 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.

Requirements

Level II - 3 years experience in clinical and health insurance or other healthcare related field AND 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 (Applies to All Levels)
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)
Intermediate PC proficiency (All Levels)
Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones (All Levels)
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, and advanced ability to interpret contract language and benefits AND 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 (Applies to All Levels)
Advanced PC proficiency
Knowledge of Current CPT, ICD- 9, ICD-10, HCPCS, and DRG coding
Working knowledge of McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies
Advanced ability to interpret contract language and benefits

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
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.
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.
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 management’s 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 “Living 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).
Each progressive level includes the ability to perform the essential functions of any lower levels.
Perform all other duties as assigned