Medical Appeals and Grievance (MAG) Registered Nurse Specialist II - Remote

About the role

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.

Responsibilities

• 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.

Qualifications

• Required Work Experience: 1 year Experience in clinical and health insurance or other healthcare related field. Level 2: 3 years' Experience in clinical and health insurance or other healthcare related field. Level 3: 5 years' Experience in clinical and health insurance or other healthcare related field. Level 4: 8 years' Experience in clinical and health insurance or other healthcare related field.
• Required Education: Associate’s Degree in a healthcare field of study or Nursing Diploma (Applies to All Levels).
• Required Licenses: Active, current, 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).
• Preferred Qualifications: 3 years' Experience in clinical and health insurance or other healthcare related field. Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies. Advanced ability to interpret contract language and benefits. Level 2: 5 years' Experience in clinical and health insurance or other healthcare related field. Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies. Advanced ability to interpret contract language and benefits. 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). Level 3: 7 years' Experience in clinical and health insurance or other healthcare related field. Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies. Advanced ability to interpret contract language and benefits. 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). Level 4: 9 years' Experience in clinical and health insurance or other healthcare related field. Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies. Advanced ability to interpret contract language and benefits. 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).

Skills

• Intermediate PC proficiency.
• Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones.

Benefits

Our Commitment AZ Blue does not discriminate against any applicant or employee because of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or any other characteristic protected by law.