Initial Clinical Reviewer - Medicare
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
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
Essential Job Functions & Responsibilities
• Identify, research, process, resolve and respond to customer inquiries and correspondence via telephone, written communication and/or in person.
• 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:
o Collaborate with team to distribute workload/work tasks;
o Monitor and report team tasks;
o Communicate team issues and opportunities for improvement to supervisor/manager;
o Support/mentor team members.
• 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.
• 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.
Within BCBSAZ and HCA, it is essential that we create a culture of inclusion and opportunity as well as actively guard against bias of any kind. Discrimination and racism are real. Our aim is to empower every member of our team to engage in our mission of improving health for Arizonans. We believe that the power and perspective of diversity and inclusion is in fact, essential to our success in serving clients, achieving our mission and creating a healthy environment for all.
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
• 2 years of experience in clinical field of practice, health insurance, or other health care related field
2. Required Education
• Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program
3. Required Licenses
• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LPN, LPT, LBSW, LMSW, or LCSW.
4. Required Certifications
1. Preferred Work Experience
• 3 years of experience in clinical field of practice, health insurance, or other health care related field
2. Preferred Education
• Bachelor's Degree in Nursing or related field of study
3. Preferred Licenses
• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse
4. Preferred Certifications
1. Required Job Skills
• Intermediate PC proficiency
• Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
2. 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
3. Required Leadership Experience and Competencies
• Resolve conflicts
• Represent BCBSAZ in the community
1. Preferred Job Skills
• Advanced PC proficiency
• Knowledge of CPT-4 and ICD-9 coding
2. Preferred Professional Competencies
• Knowledge of managed care, utilization management, and quality management
• Working knowledge of McKesson InterQual® criteria
3. Preferred Leadership Experience and Competencies