Grievance & Appeals Nurse - Medicare Advantage
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
This position serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution and responses are processed promptly in accordance with CMS requirements and timelines.
Essential Functions and Job Responsibilities
• Maintains a thorough understanding of Health Plan operations and business unit processes, work flows and system requirements, including, but not limited to, plan benefits as outlined in the Explanation of Coverage (EOC) documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance.
• Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
• Participates in CMS and other audits and related activities as required.
• Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations.
• Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day.
• 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
1. Required Work Experience
• 5 years of work experience with CMS member services, prior authorizations, appeal and grievance, or claims functions.
2. Required Education
• Associate’s Degree in a healthcare field of study or Nursing Diploma
3. Required Licenses
• Licensed Practical Nurse or Registered Nurse with a current, active, unrestricted nursing license in the state of Arizona (a state in the United States).
4. Required Certifications
1. Preferred Work Experience
• 1-3 years prior work experience in a managed care environment.
2. Preferred Education
• Bachelor’s degree in general studies, nursing, or business administration
3. Preferred Licenses
4. Preferred Certifications
1. Required Job Skills
• 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
• Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes, accurate and efficient keyboarding skills, and the ability to work effectively with common office software.
• Math, communications and business skills normally demonstrated by a high school degree or equivalent.
2. Required Professional Competencies
• Demonstrated ability to evaluate and interpret medical records and health plan benefit documents to make appropriate benefit determinations.
• Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation.
3. Required Leadership Experience and Competencies
1. Preferred Job Skills
2. Preferred Professional Competencies
3. Preferred Leadership Experience and Competencies