Job Description

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.

Purpose of the job

Performs triage (intake, classification, case file setup and assignment) of Medicare Part C and D grievances and appeals; provides administrative, clerical, and other related support to the Grievance and Appeals (G&A) staff; establishes, maintains, and monitors grievance and appeal workload tracking and workflow processes; assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met; completes day-to-day operational tasks assigned according to defined processes and procedures; prepares G&A case file folders and assists with tracking and maintaining G&A case records and files; and assists with collecting and reporting G&A related performance and regulatory data.

 

ESSENTIAL job functions AND RESPONSIBILITIES

 
 
  • Receive, sort, classify, prioritize, manage, and distribute inbound G&A mail, fax, inter-office, and other correspondence according to policies and procedures, the CMS Managed Care and Prescription Drug Benefit Manuals, and other regulatory and procedural rules, guidelines and timeframes.
  • Prepare and assign individual case files to the appropriate G&A staff, continuously update tracking logs, databases, and reports, monitor and manage case status, timelines, statistics, regulatory compliance and performance as required.
  • Prepare and mail, fax, inter-office, and other outbound correspondence.
  • Coordinate with enrolled members and providers submitting grievances and appeals to obtain additional information or clarification as required.
  • Coordinate case files with G&A Staff (administrative evaluation of timely filing, claim payments, insufficient information, etc.), Quality Management staff (quality of care issues) Medical Directors (clinical evaluation of covered services, appropriate level of care, medical necessity, quality of care, etc.) and/or the Chief Medical Officer (clinical evaluation of covered services, appropriate level of care, medical necessity, quality of care, etc.) as required.
  • Assist in the preparation and submission of cases to the Independent Review Entity (IRE), as required.
  • Receive and coordinate Administrative Law Judge (ALJ), Medicare Appeals Council (MAC), and Federal District Court cases with the G&A staff, Medical Director, Legal, and other departments as required.
  • Provide information regarding rights and responsibilities to enrolled members, providers, and other QHP departments as outlined in the Medicare Managed Care Manual.
  • 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.

 

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.

Skills / Requirements

Qualifications

REQUIRED QUALIFICATIONS

  1. Required Work Experience
  • 2 years of experience in a Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) insurance plan and/or other managed care organization.
  1. Required Education
    • High school diploma or GED in general field of study.
  1. Required Licenses
  • N/A
  1. Required Certifications
  • N/A

PREFERRED QUALIFICATIONS

  1. Preferred Work Experience
  • 2 years of additional experience, including working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes
  1. Preferred Education
  • N/A
  1. Preferred Licenses
  • N/A
  1. Preferred Certifications
  • N/A

 

competencies

REQUIRED COMPETENCIES

  1. Required Job Skills
    • Math, communications and business skills normally demonstrated by a high school degree or equivalent.
    • Intermediate PC user, including Microsoft Word, Excel, Outlook, Power Point, and Adobe Acrobat Pro.
    • Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones.
  1. Required Professional Competencies
    • Maintain confidentiality and privacy as outlined by HIPAA.
    • Strong critical thinking skills.
    • Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation, and practice interpersonal and active listening skills to achieve customer satisfaction.
    • Compose a variety of business correspondence
    • Interpret and translate policies, procedures, programs and guidelines
    • Strong investigative and analytical research skills
    • 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
  1. Required Leadership Experience and Competencies
  • N/A

PREFERRED COMPETENCIES

  1. Preferred Job Skills
  • N/A
  1. Preferred Professional Competencies
  • N/A
  1. Preferred Leadership Experience and Competencies
  • N/A
 

Application Instructions

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