Registered Nurse-Medical Review Lead (Medical Review, Claims processing/UM experience in a Lead role preferred)
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.
Assists the Manager, Medical Review with performing duties to oversee day-to-day activities within the Medical Claims Review Department to facilitate the achievement of business goals and targets. Support management with leading Medical Review team to ensure all types of claims requiring medical reviews are completed in compliance with State, Federal, accreditation standards and other applicable regulations.
- Assist with the development and review of l key workflows, policies and procedures and job aids at least annually. Under the direction of the Manager, Medical Review, updates/revises workflows, policies and procedures and job aids as needed.
- Assist with assigning work queues and oversight for key performance indicators
- Oversee day-to-day activities, including inventory management to meet departmental and corporate timeliness standards
- Assist with improving the 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
- Maintain a thorough knowledge of evidence-based criteria and other policies
- Assist with the validation and confirmation of follow through of the medical review decisions.
- Assist with the development, execution and evaluation of desk level procedures and job aids
- Assist with the reviewing, updating and accurate documentation, computer files, policies and procedures related to the departmental goals and objectives.
- Assist with maintaining all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements
- Assist with the implementation of quality assurance process, procedures, and measure for team activities.
- Assist with providing motivation and encouragement to team.
- Assist with interviews and candidate selection
- This position requires a full-time work schedule
- Performs all other duties as assigned
Assist leadership with deployment of strategic initiatives and Perceptyx plan.
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
Job Reference #: 5445