Registered Nurse-Initial Clinical Reviewer - Commercial Prior Auth

Job Description

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.

Responsible 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.

• Identify, 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 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 all other duties as assigned.

Required Work Experience

2 year(s) of experience in clinical field of practice, health insurance, or other health care related field (Prior UM experience preferred)

Required Education

Associate’s Degree in general field of study or Post High School Nursing Diploma

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 or LCSW.

Preferred Work Experience

3 year(s) of experience in clinical field of practice, health insurance, or other health care related field

Preferred Education

Bachelor's Degree in Nursing or related field of study

Preferred Licenses

Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse

Required Job Skills

• Intermediate PC proficiency
• Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones

Required Professional Competencies

• Maintain confidentiality and privacy
• Strong current clinical knowledge
• Practice interpersonal and active listening skills to achieve customer satisfaction
• Compose a variety of business correspondence
• Interpret and translate policies, procedures, programs and guidelines
• Capable of investigative and analytical research
• Navigate, gather, input and maintain data records in multiple system applications
• Follow and accept instruction and direction
• Establish and maintain working relationships in a collaborative team environment
• Organizational skills with the ability to prioritize tasks and work with multiple priorities
• Independent and sound judgment with good problem solving skills

Required Leadership Experience and Competencies

• Resolve conflicts
• Represent BCBSAZ in the community
30+ days ago