RN Med Policy Development/Research Specialist (UM experience) - REMOTE-AZ

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 medical technology research to support the Medical Director Staff and Medical Policy Panel with decisions to ensure that medical policies are consistent with the standards of accepted medical practice in the community.
• Recognize the necessity of an external consultant review concerning a coverage guideline or new technology, summarizing and reporting this information to management to facilitate the process as outlined for Level II.
• Initiate research from resource materials, e.g., clinical journals, periodicals, CMS (Medicare) guidelines and publications, BCBSA publications, other BCBS plans, and internet resources relating to technical, clinical and coverage guidelines, summarizing and reporting this information to management for further action.
• Perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.
• Coordinate all aspects of the Medical Policy Panel and Medical Director Meeting, including preparation, agenda and minutes.
• Provide oversight to responsible staff for the monthly review of BCBS Association Medical Policy and Reference Manual (MPRM) updates.
• Designate the oversight of staff regarding training of new staff at the desk level of instruction/training.
• Perform advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.

Requirements

• Required Work Experience: 2 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels); 1 year(s) of experience in medical policy and technology research field (Applies to Level 2); 2 year(s) of experience in medical policy and technology research field (Applies to Level 3).
• Required Education: Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program (Applies to All Levels).
• Required Licenses: Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LPN, LPT, LBSW, LMSW, or LCSW. (Applies to All Levels).
• Preferred Qualifications: 3 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels); 1 year(s) of experience in claims retrospective review, utilization management, case management, appeals and grievances or quality review field (Applies to All Levels).
• Preferred Education: Bachelor's Degree in Nursing or related field of study (Applies to All Levels).
• Preferred Licenses: Active, current, and unrestricted State of Arizona (a state in the United States) license to practice as a Registered Nurse (Applies to All Levels).

Qualifications

• Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program (Applies to All Levels).
• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LPN, LPT, LBSW, LMSW, or LCSW. (Applies to All Levels).

Skills

• Intermediate PC proficiency.
• Intermediate Adobe PDF Standard proficiency.
• Intermediate word processing, spreadsheet and presentation software proficiency (Applies to All Levels).

Benefits

Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.

Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.