Job Description

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.

This remote work opportunity requires residency, and work to be performed, within the State of Arizona.

Manager of Appeals and Grievance Coordination is responsible for providing direction and oversight of assigned Appeal and Grievance Coordination employees.  Responsible to ensure the department’s work activities comply with service, regulatory and accreditation standards. Responsible for developing and implementing a strategy to coordinate and resolve member/provider grievances, non-clinical appeals, and timely and accurate transferring of clinical appeals. This position maintains departmental strategies, goals and objectives, while providing the desired customer service approach with both internal and external contacts. 

REQUIRED QUALIFICATIONS

Required Work Experience
  • 10 years of experience in healthcare related field
  • 5 years of experience in a supervisory role

Required Education

  • High-School Diploma or GED in a general field of study

Required Licenses

  • N/A

Required Certifications

  • N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience
  • 4 years of experience in management  or supervisory role

Preferred Education

  • Associate's Degree in healthcare or business-related field of study
  • Bachelor’s Degree in healthcare or business-related field of study

Preferred Licenses

  • N/A
Preferred Certifications
  • N/A

ESSENTIAL job functions AND RESPONSIBILITIES

  • Manages and advises the organization on an effective grievance and appeals system consistent with policies and procedures, department goals and regulatory requirements
  • Knowledgeable of AZDOI, DOL, and ACA rules and regulations
  • Maintains and updates all related policies and procedures, and desktop procedures
  • Advanced knowledge of claims and/or utilization management processes
  • Actively participates in URAC audits and related activities. Responsible for resolving any identified findings through corrective action, in collaboration with the compliance, quality and/or medical appeals team
  • Actively monitors grievance and appeal activity to identify any trends, and correct non-compliance or processing errors. Monitors processing timeliness, verbal and written communications and case volume
  • Coordinates investigations and resolution of complex grievances and non-clinical appeal issues
  • Reports to committees as required
  • Administer, interpret and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals.
  • Maximizes the use of available data to manage, summarize and report on grievance and appeals trends, productivity and compliance.
  • Responsible for the review, update and accuracy of documentation related to the departmental goals and objectives.
  • Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies as a representative of the area of responsibility.
  • Identify, research, process, resolve and respond to customer inquiries and correspondence via telephone, written communication and/or in person.
  • Keep status of the unit current in accordance with service standards, systems, procedures, forms and manuals through staff meetings and verbal and written communications.
  • Recruits, provide motivation and encouragement to subordinates, conduct performance evaluations, identify and coordinate training needs, make determinations regarding disciplinary actions.
  • 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 COMPETENCIES

Required Job Skills

  • Advanced skill in use of office equipment including copier, fax machine, scanner and telephones
  • Advanced PC proficiency
  • Advanced skill in word processing, spreadsheet and database software
  • Advanced claims processing knowledge
  • Advanced knowledge of benefits and cross-functional processes
  • Advanced knowledge of managed care processes

Required Professional Competencies

  • Maintain confidentiality and privacy
  • Management experience
  • Strategic and problem-solving skills
  • Leadership skills
  • Strong interpersonal skills
  • Ability to assess high risk issues and escalate as appropriate
  • Strong verbal and written communication skills
  • Conflict resolution and coaching techniques

Required Leadership Experience and Competencies

  • Make use of employees' skills and abilities to deliver business objectives
  • Use available information to focus the team's activities and identify priorities

PREFERRED COMPETENCIES

Preferred Job Skills

  • Understanding of workflow systems to maximize resources and streamline processes for efficiency

Preferred Professional Competencies

  • N/A

Preferred Leadership Experience and Competencies

  • N/A

Our Commitment

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.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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