Blue Cross Blue Shield of Arizona
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Registered Nurse Medical Appeals and Grievance Specialist I-III
at Blue Cross Blue Shield of Arizona
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.
Responsible for utilizing clinical acumen and managed care expertise related to researching, resolving and responding to requests for member and provider appeals, grievances, reconsiderations and corrected claims for all lines of business with emphasis on privacy, accuracy, meeting all regulatory and compliance timelines.
- Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
- Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
- Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
- Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration 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.
- 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.
- Attend staff and interdepartmental meetings.
- 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.
- Maintain productivity and accuracy goals based on regulatory requirements, accreditation standards, and service level agreements.
- Demonstrate ability to acquire specialized knowledge to complete all types of level one appeals, grievances and corrected claims for local lines of business using appropriate benefit plan booklet, administrative guidelines and policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research and precertification research.
- Articulate to customers a variety of information about the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, and provider networks.
- Adheres to BCBSAZ brand promise of being a “Trusted Advisor” by walking in the customers shoes including processing work using the principles of easy, effective, emotional
- Ability to demonstrate specialized knowledge to administer Federal Employee Program (FEP)inquiries, appeals, grievances and sub-reconsiderations using appropriate service benefit plan provisions, and internal policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research, and precertification research.
- Ability to demonstrate specialized knowledge to perform reviews for local lines of business, Blue Card Home member appeals and grievances, and Blue Card Host provider grievances. MAG Clinicians also support FEP for member reconsiderations, provider appeals, corrected claims and inquiries.
- Ability to demonstrate specialized knowledge to complete all Levels of Medical Appeals and Grievance (MAG) cases (Initial internal, voluntary internal and external review appeals and grievances).
- Under minimal direction, lead interdepartmental meetings and oversee special projects as assigned.
- Assist in developing new policies and procedures, desk levels, and job aids as needed.
- Assist in training new staff and provide ongoing training for existing staff as needed.
- Assist in distribution of staff Flow Manager case assignments.
- Identify and recommend process improvements.
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.