Appeal and Grievance Coordination Research Reviewer (1 yr exp in claims processing/precert or A/G in a health plan)
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering 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.
Internal use only-Grade 13-15
Performing research and processing of appeals, grievances, corrected claims, medical records and related correspondence in accordance with BCBSAZ, State, Federal and other accreditation requirements as applicable.
Required Work Experience
- 1 years of experience in claims processing, medical/ pharmacy precertification, appeals and grievances coordination or other applicable related work experience(Applies to All Levels)
- High-School Diploma (Applies to All Levels) or higher
PREFERRED QUALIFICATIONSPreferred Work Experience
- 2 years of experience in a lead or senior claims role (Applies to All Levels)
- 3 years of experience in claims processing and correspondence with multiple claims systems (All Levels)
- 2 years of experience in the medical or healthcare related field (Applies to All Levels)
- 3 years as a pharmacy technician or precertification technician
- Bachelor’s degree in business/healthcare or related field
- Certified Coder
ESSENTIAL job functions AND RESPONSIBILITIES
- Perform analysis and research of requests received for medical grievances, appeals for final resolution or referral to the Clinical Medical Appeals and Grievance (MAG) Staff.
- Maintains advanced end user knowledge of multiple systems including vendor medical management and claims systems
- Conduct research to resolve requests received from members, providers and other Blue Plans in accordance with State, Federal, BlueCard and URAC timeliness standards.
- Review medical records to determine if records satisfy the requested or supporting information required.
- Complete specific Appeals and Grievances after clinical training.
- Maintain current medical terminology knowledge.
- Identify research and assemble medical records, coverage guidelines, claims and historical data for MAG staff review and presentation to the Medical Director, Department of Insurance, Executive Inquiries or other legal proceedings.
- Perform data corrections and initiate adjustments related to appeals originating from the Medical Grievance and Appeals Department. Communicate decisions through appropriate system updates.
- Analyze and monitor appeals, grievances, and insufficient records to identify possible trends or patterns and document and report findings to Supervisor and/or Manager with suggestions and follow-up.
- Assist in utilization studies and analysis.
- Meet department and individual contributor goals.
- Performs activities with limited supervision.
- Use pharmacy system to research and prepare level 2 and external pharmacy cases
- Monitor proxy box for pharmacy appeals and grievances
- Monitors Appeals and Grievance Coordination (AGC) proxy boxes and phones as assigned
- Demonstrates commitment to excellent customer experience.
- Maintain understanding and working knowledge of a variety of lines of business including fully insured, self-funded groups, Affordable Care Act individuals and groups, and Blue Card
- Maintain understanding of Medical Management and claims processing systems
- Process records/document requests related to appeals and grievances
- Works with vendors and special groups to ensure appropriate communication between levels of appeals including sending required documentation to group/vendor contact
- Researches and reopens claims appeals for diagnosis mismatch
- Researches and communicates with legal team as directed by leadership, including assisting with written communication
- Attest to training competency related to medical terminology and new/revised processes
- Ensure HIPAA compliance/PHI privacy
- Communicates with privacy office as indicated related to CMS1557 discrimination grievance requests
- Assists with research and preparation of appeals files for accreditation site visits
- Completes mandatory training and 3 or more additional training courses
- Completes IDP and participates in Perceptyx action plan
- Maintain current knowledge and understanding of State, Federal, BCBSAZ, Blue Card, and accreditation requirements as applicable, pertaining to appeal and grievance timeframes, processing, tracking, analysis and reporting to ensure case reviews are completed accurately and timely.
- Other duties as assigned
- Perform Level 1-2 activities independently.
- Identify and report trends seen in grievances, appeals, and medical records to management.
- Assist Claims Department with customer inquiries.
- Assist with questions and training for Level 1 Reviewers.
- Perform focused quality sampling audits and report findings to management.
- Attend Blue Cross Blue Shield Association appeals and grievance roundtable meetings as assigned
- Assist with working aging report as assigned
- Assist with case assignment as assigned
- Perform Level 1-3 activities independently.
- Initiate adjustments at time of final determination or coordinate with appropriate department for resolution.
- Process Blue Card requests.
- Participate on special teams and projects as needed, related to claims, recoupments, coding related to medical coverage guidelines
- Create job aids and assist to maintain desk level procedures.
- Provide training and mentoring of staff.
- Perform focused quality sampling audits and report findings to management.
- Conduct Timely Filing reviews for Level 2 requests.
- Perform User Acceptance Testing (UAT) for system upgrades
- Each progressive level includes the ability to perform the essential functions of any lower levels.
- The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
- Perform all other duties as assigned.
Required Job Skills
- Intermediate PC proficiency (Applies to All Levels)
- Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones (All Levels)
- Intermediate skill in word processing, spreadsheet and database software (Applies to All Levels)
- Intermediate written communication and letter writing skills
Required Professional Competencies
- Maintain confidentiality and privacy (Applies to All Levels)
- Ability to perform investigative and analytical research (Applies to All Levels)
- Establish and maintain working relationships in a collaborative team environment (Applies to All Levels)
- Practice interpersonal and active listening to achieve high customer satisfaction and departmental communication standards (Applies to All Levels)
- Interpret and translate policies, procedures, programs and guidelines (Applies to All Levels)
Required Leadership Experience and Competencies
Preferred Job Skills
- Advanced PC proficiency (Applies to All Levels)
- Advanced skill in word processing, spreadsheet and database software (Applies to All Levels)
- Advanced written communication/letter writing (All Levels)
Preferred Professional Competencies
- Navigate, gather, input and maintain data records in multiple systems applications (Applies to All Levels)
- Understand claims processing logic (Applies to All Levels)
- Knowledge of contract benefits and administrative guidelines (Applies to All Levels)
Preferred Leadership Experience and Competencies
- Experience in a lead or senior claims role (Applies to All Levels)
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
Imagine doing life-changing work and helping more than one million Arizonans live healthier and longer lives. That’s the kind of satisfaction you’ll find when you work here. Our exceptional teams in Phoenix, Tucson, Chandler, and Flagstaff have been transforming healthcare for more than 80 years. Explore what's possible with a career at Blue Cross® BlueShield® of Arizona