High-Cost Claimant Review Unit Nurse Auditor (Remote in AZ)

PURPOSE OF THE JOB

This position is responsible for assessment and documentation of member utilization and prediction of future spend feeding internal and external customer reporting. Primary responsibilities include:

• Function as a designated clinical resource to review High Cost Claimants to identify opportunities to improve member outcomes and determine correct utilization of resources
• Collaborate with multi-disciplinary teams to determine if there are other resources, BCBSAZ programs, or community resources that can curtail benefit spend or improve outcomes
• Focus on enhancing customer relationship and service as the primary clinical point of contact

Required Qualifications

• 5 years of experience working within a healthcare and/or management care
• 2 consecutive years’ experience as an RN analyst or auditor in Utilization Review, Medical Claim Review and/or Care Management
• Associate's Degree in Nursing or related field of study
• Active, unrestricted license to practice as a registered nurse (RN) in the state of Arizona

Preferred Qualifications

• 7 years’ experience working within a healthcare and/or management care
• 3 years’ experience with managing direct customer facing or account management experience
• Experience in working in more than one of Utilization Management, Medical Claim Review and Care Management
• Experience with working with VITAL, Metavance and/or Guiding Care platforms
• Experience in operational analysis, data analysis and problem resolution types of activities

Essential Job Functions And Responsibilities

• Analyze utilization data from provided sources to evaluate cost drivers.
• Apply clinical knowledge, incorporating the persistency score to determine if member care needs will be ongoing versus an acute episodic.
• Apply knowledge of customer benefit structure to determine appropriate use of services.
• Collaborate with multi-disciplinary team to determine if there are other resources; BCBSAZ programs, community resources that can curtail benefit spend or improve outcomes.
• Document findings in a manner that can be consumed by internal process for reporting purposes, internal and external customers.
• Refer the member to appropriate internal BCBSAZ group to manage and coordinate care as indicated.
• Continue to evaluate the member’s benefit spend according to Key Decision Criteria.
• Responsible for the professional, efficient and timely delivery of services to members and customer/Group Benefit Administrator requesting assistance.
• Provide proactive clinical recommendations, information regarding trends, program and industry changes the customer and member experience.
• Represent customer-internally and coordinate with other departments such as medical and pharmacy account team to address ongoing needs, implement care initiatives, projects and customer systems.
• Lead process improvement initiative and projects to improve the delivery of services.
• Lead efforts to identify best practices and resources required to support customer with meeting business commitments and enhance member experience.
• Develop relationships and establish credibility with key stakeholders (internal and external) to achieve solution strategies and objectives.
• Routinely collaborate with account management team to provide clinical aspects of High Cost Claimant reviews.
• Able to analyze and interpret benefit designs and identify opportunities to increase efficiency.
• Complete High Cost Claimant screening and analysis to identify trends and opportunities; present findings to key stakeholders and clinical leadership.
• Support clinical quality audit activities under the direction of manager to identify opportunities to deliver on commitments and enhance customer satisfaction/experience.

Leadership

• Maintain effective working relationships to ensure teamwork in achieving company goals.
• Foster effective communication with business partners by setting clear directives and providing exchange of ideas.
• Provide leadership on change management principles to ensure maximize benefit and alleviate unnecessary disruption.
• Effectively communicates analytical and reporting needs to supporting departments.
• Identify and create opportunities to manage trend(s).

Administrative

• Manage use of corporate funds including budgeting, financial management, and reporting.
• Identify opportunities to achieve administrative efficiencies while maintaining service.
• Establish performance goals in accordance with overall BCBSAZ objectives and divisional strategic planning.
• Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve Business goals/objectives.
• Ensure the existence of documented policies and procedures.
• Cookordinate activities between multiple divisions to achieve desired results.
• Volunteer within the community to help BCBSAZ give back to community charitable efforts.
• Ability to travel up to 25% of time to attend work related customer, business meetings, trainings and conferences.
• 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 other duties as assigned.