Medical Appeals and Grievance (MAG) 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.

Requirements

• Required Work Experience Level 1: 1 year' Experience in clinical and health insurance or other healthcare related field
• Required Work Experience Level 2: 3 years' Experience in clinical and health insurance or other healthcare related field
• Required Work Experience Level 3: 5 years' Experience in clinical and health insurance or other healthcare related field
• Required Work Experience 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)
• Required Certifications: N/A

Qualifications

• Preferred Work Experience Level 1: 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
• Preferred Work Experience 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
• Preferred Work Experience 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
• Preferred Work Experience 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
• Preferred Education: Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
• Preferred Licenses: N/A
• Preferred Certifications: N/A

Skills

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

Benefits

This position is remote within the state of AZ only. This remote work opportunity requires residency, and work to be performed, within the BCBSAZ Approved states.

Pay

The pay range for this role is $60,000 - $100,000 annually.

Schedule

The position has an onsite expectation of 0 days per week and 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.