Initial Clinical Reviewer - Remote AZ

About the position Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make 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 make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This remote work opportunity requires residency, and work to be performed, within the State of Arizona. 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.

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: Collaborate with team to distribute workload/work tasks; Monitor and report team tasks; Communicate team issues and opportunities for improvement to supervisor/manager; 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.
• Perform all other duties as assigned.

Requirements

• 2 years of experience in clinical field of practice, health insurance, or other health care related field
• Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program
• Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN, OR an active, current, and unrestricted license to practice in the State of Arizona as an LPN.
• Intermediate PC proficiency
• Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
• 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
• Resolve conflicts
• Represent BCBSAZ in the community

Nice-to-haves

• 3 years of experience in clinical field of practice, health insurance, or other health care related field
• Bachelor's Degree in Nursing or related field of study
• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse
• Advanced PC proficiency
• Knowledge of CPT-4 and ICD-9 coding
• Knowledge of managed care, utilization management, and quality management
• Working knowledge of McKesson InterQual® criteria