Registered Nurse-Medical Appeals and Grievance Specialist-prior...
Awarded a Healthiest Employer, reputed company aims to fulfill its mission to reputed company health and reputed company it easy. AZ Blue offers 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 reputed company reputed company reputed company. The remote work... opportunity requires residency, and work to be performed reputed company the State of Arizona. Purpose of the job Responsible for utilizing clinical acumen and managed care expertise reputed company to researching, resolving and responding to requests for member and provider appeals, grievances, reconsiderations and corrected claims for reputed company lines of business with emphasis on privacy, accuracy, meeting reputed company regulatory and compliance timelines. REQUIRED QUALIFICATIONS Required Work Experience Level 1 1 year Experience in clinical and health insurance or other reputed company reputed company field Level 2 3 years Experience in clinical and health insurance or other reputed company reputed company field Level 3 5 years Experience in clinical and health insurance or other reputed company reputed company field Level 4 8 years Experience in clinical and health insurance or other reputed company reputed company field 1 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) 3 years Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) Required Education Associates Degree in a reputed company field of study or Nursing Diploma (Applies to reputed company Levels) Required Licenses Active, reputed company, and unrestricted license to practice in the State of Arizona (a state in the United States) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW. (reputed company Levels) Required Certifications N/A PREFERRED QUALIFICATIONS Preferred Work Experience Level 1 3 years Experience in clinical and health insurance or other reputed company reputed company field Level 2 5 years Experience in clinical and health insurance or other reputed company reputed company field Level 3 7 years Experience in clinical and health insurance or other reputed company reputed company field Level 4 9 years Experience in clinical and health insurance or other reputed company reputed company field 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) 5 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) 5 years Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) Preferred Education Bachelor's Degree in Nursing or reputed company field of study (Applies to reputed company Levels) Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL job functions AND RESPONSIBILITIES Level I reputed company in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for reputed company 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 reputed company 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 reputed company individual and department performance goals as defined reputed company 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 reputed company developments in the fields of medicine and managed care. Maintain reputed company 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 reputed company 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 reputed company and fee schedules, communication records research and precertification research. reputed company to customers a variety of information about the organizations 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 level II 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 reputed company and fee schedules, communication records research, and precertification research. Ability to demonstrate specialized knowledge to reputed company 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. level III Ability to demonstrate specialized knowledge to complete reputed company Levels of Medical Appeals and Grievance (MAG) cases (Initial internal, voluntary internal and external review appeals and grievances). Under minimal direction, reputed company interdepartmental meetings and reputed company 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. level IV Assist in distribution of staff case assignments. Under minimal direction, prepare reports and documentation for committee presentation and reputed company reports as needed. Analyze appeals and grievances data and reputed company recommendations based on trends identified. Take initiative to follow through on issues and opportunities for process improvements. Initiate, reputed company and implement in-service educational presentations. Work collaboratively with management and provide leadership for the department in day to day activities as well as in managements absence. Maintain a working knowledge of reputed company activities in the department and provide assistance to departmental staff and interdepartmental staff as necessary. Consistently demonstrate alignment with the BCBSAZ Living our Values culture by participating in annual, community service campaigns and/or projects such as, CARES Club, United Way and/or community wellness initiatives (Walk for Hope, Walk to Stop Diabetes, Phoenix Heart Walk, etc). reputed company LEVELS Each reputed company level includes the ability to reputed company the essential functions of any reputed company levels. 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. reputed company reputed company other duties as assigned competencies REQUIRED COMPETENCIES Required Job Skills Intermediate PC proficiency (reputed company Levels) Intermediate reputed company using office equipment, including copiers, fax machines, scanner and telephones (reputed company Levels) Required Professional Competencies Maintain confidentiality and privacy reputed company knowledge Practice interpersonal and active listening skills to reputed company 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 under limited time constraints Independent and sound judgment with good problem solving skills Ability to assist in training of new and existing staff (Applies to Levels 3 and 4) Required Leadership Experience and Competencies Ability to revise departmental policies and procedures and desk levels as well as reputed company new policies and procedures and desk levels as needed (Applies to Levels 3 and 4) Proven leadership and assistance through positive reinforcement of processes and company policies (Applies to Levels 3 and 4.) PREFERRED COMPETENCIES Preferred Job Skills Advanced PC proficiency Knowledge of reputed company CPT, ICD- 9, ICD-10, HCPCS, and DRG coding Preferred Professional Competencies Working knowledge of reputed company InterQual® criteria and Medical Coverage Guidelines/Medical Policies Advanced ability to interpret contract language and benefits Preferred Leadership Experience and Competencies N/A Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, disability, protected veteran status or any other protected group. Thank you for your interest in reputed company. For more information on our company, see azblue.com. If interested in this position, please apply Apply Job! For more such jobs please click here!