Bh um clinical reviewer- remote az Job at Blue Cross Blue Shield of Arizona (Phoenix)

Job Description

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. This job description is primary for utilization management functions but can assist with care management if a business need arises.

Job Responsibility

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 daily
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, behavioral health and managed care at least annually
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

Requirements

2 year(s) of experience in clinical field of practice, health insurance, or other health care related field
Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D.
Active, 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.

Nice to have

3 year(s) of experience in clinical field of practice, health insurance, or other health care related field
1-2 year(s) of experience working in a managed care organization
Bachelor's Degree in Nursing or related field of study
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse
Advanced PC proficiency
Knowledge of CPT 2018 and ICD-10 coding
Knowledge of managed care, utilization management, and quality management
Working knowledge of McKesson InterQual® criteria, MCG, ASAM, or other nationally recognized criteria

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Bh um clinical reviewer- remote az

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