Initial Clinical Reviewer - Remote - AZ

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 weekHybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per weekHybrid 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 monthOnsite: daily onsite requirement based on the essential functions of the jobRemote: 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 buildingPlease 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 JOBResponsible 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.QUALIFICATIONSREQUIRED QUALIFICATIONSRequired Work Experience2 years of experience in clinical field of practice, health insurance, or other health care related fieldRequired EducationAssociate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved programRequired LicensesActive, 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.Required CertificationsN/APREFERRED QUALIFICATIONSPreferred Work Experience3 years of experience in clinical field of practice, health insurance, or other health care related fieldPreferred EducationBachelor's Degree in Nursing or related field of studyPreferred LicensesActive, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered NursePreferred CertificationsN/AESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIESIdentify, 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.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 requirementsPerform all other duties as assigned.COMPETENCIESREQUIRED COMPETENCIESRequired Job SkillsIntermediate PC proficiencyIntermediate skill in use of office equipment, including copiers, fax machines, scanner and telephonesRequired Professional CompetenciesMaintain confidentiality and privacyStrong current clinical knowledgePractice interpersonal and active listening skills to achieve customer satisfactionCompose a variety of business correspondenceInterpret and translate policies, procedures, programs and guidelinesCapable of investigative and analytical researchNavigate, gather, input and maintain data records in multiple system applicationsFollow and accept instruction and directionEstablish and maintain working relationships in a collaborative team environmentOrganizational skills with the ability to prioritize tasks and work with multiple prioritiesIndependent and sound judgment with good problem solving skillsRequired Leadership Experience and CompetenciesResolve conflictsRepresent BCBSAZ in the communityPREFERRED COMPETENCIESPreferred Job SkillsAdvanced PC proficiencyKnowledge of CPT-4 and ICD-9 codingPreferred Professional CompetenciesKnowledge of managed care, utilization management, and quality managementWorking knowledge of McKesson InterQual criteriaPreferred Leadership Experience and CompetenciesN/AOur CommitmentAZ 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. #J-18808-Ljbffr