Behavioral Health-Clinical Reviewer-Prior BHUM & Managed Care experience desired
Awarded the Best Place to Work 2021, 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.
- Responsible for identifying, researching, processing, resolving and responding to inquiries from internal and external customers with emphasis on excellence, privacy, compliance and versatility within the health insurance industry. This job description is primary for utilization management functions but can assist with care management if a business need arises.
Required Work Experience
- 2 year(s) of experience in clinical field of practice, health insurance, or other health care related field
- Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification from an approved program or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, independent license in the behavioral health profession such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D).
PREFERRED QUALIFICATIONSPreferred Work Experience
- 3 year(s) of experience in clinical field of practice, health insurance, or other health care related field
- 1-2 year (s) of experience working in a managed care organization
- Bachelor's Degree in Nursing or related field of study
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse
ESSENTIAL job functions AND RESPONSIBILITIES
- Answer a diverse and high volume of health insurance related customer calls or correspondence on a daily basis.
- Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit 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.
- Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc.
- 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.
- When indicated to assist with team/project functions:
- Collaborate with team to distribute workload/work tasks;
- Monitor and report team tasks;
- Communicate team issues and opportunities for improvement to supervisor/manager;
- Support/mentor team members.
- Participate in continuing education and current developments in the fields of medicine, behavioral health and managed care at least annually.
- Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements.
- 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
- Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Required Professional Competencies
- Maintain confidentiality and privacy
- Strong current 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
- Independent and sound judgment with good problem solving skills
Required Leadership Experience and Competencies
- Resolve conflicts
- Represent BCBSAZ in the community
Preferred Job Skills
- Advanced PC proficiency
- Knowledge of CPT 2018 and ICD-10 coding
Preferred Professional Competencies
- Knowledge of managed care, utilization management, and quality management
- Working knowledge of McKesson InterQual® criteria, MCG, ASAM, or other nationally recognized criteria
Preferred Leadership Experience and Competencies
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.