Initial Clinical Reviewer Job at Blue Cross Blue Shield of Arizona (Phoenix)

Initial Clinical Reviewer

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

2 years 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 Certification (LPN only) from an approved program
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, OR an active, current, and unrestricted license to practice in the State of Arizona as an LPN

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 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

Fulltime

Initial Clinical Reviewer - Remote - AZ

Responsible for identifying, researching, processing, resolving, and responding ...

Location

United States , Phoenix

Salary:

Not provided

Blue Cross Blue Shield of Arizona

Expiration Date

Until further notice

Requirements

2 years 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 Certification (LPN only) from an approved program
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, OR an active, current, and unrestricted license to practice in the State of Arizona as an LPN
Intermediate PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
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

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 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
Collaborate with team to distribute workload/work tasks
Monitor and report team tasks

Fulltime

DRG Clinical Dispute Reviewer

At Zelis, the DRG Clinical Dispute Reviewer role is responsible for the resoluti...

Location

United States , St. Petersburg; Plano; Boston; St. Louis; Atlanta

Salary:

95000.00 - 127000.00 USD / Year

Zelis

Expiration Date

Until further notice

Requirements

5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims
Current, active Inpatient Coding Certification required (ie. CCS, CIC,RHIA, RHIT, CPC or equivalent credentialing)
Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers
Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs
Understanding of hospital coding and billing rules
Clinical skills to evaluate appropriate Medical Record Coding
Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner
Background and/or understanding of the healthcare industry
Knowledge of National Medicare and Medicaid regulations
Knowledge of payer reimbursement policies

Job Responsibility

Review provider disputes for DRG Coding and Clinical Validation (MS and APR)
Review and submit explanation of dispute rationale back to providers based on dispute findings within the designated timeframe to ensure client turnaround times are met
Accountable for daily management of claim dispute volume, adhering to client turnaround time, and department Standard Operating Procedures
Serve as subject matter expert for the Expert Claim Review Team on day-to-day activities including troubleshooting and review for data accuracy
Serve as a subject matter expert for content and bill reviews and provide support where needed for inquiries and research requests
Create and present education to Expert Claim Review Teams and other departments dispute findings
Research and analysis of content for DRG reviews
Use of strong coding and industry knowledge to create and maintain claim review content, including but not limited to DRG Reviewer Rationales, DRG Clinical Validation Policies and Dispute Rationales
Perform regulatory research from multiple sources to keep abreast of compliance enhancements and additional bill review opportunities
Support for client facing teams as needed relating to client inquiries related to provider disputes

What we offer

401k plan with employer match
flexible paid time off
holidays
parental leaves
life and disability insurance
health benefits including medical, dental, vision, and prescription drug coverage

Fulltime

New

Clinic Patient Representative - Gastroenterology

Summary: Serves as the initial point of contact for patients and visitors, welco...

Location

United States , Corpus Christi

Salary:

Not provided

CHRISTUS Health

Expiration Date

Until further notice

Requirements

High School Diploma

Job Responsibility

Serves as the initial point of contact for patients and visitors, welcoming them to the Family Health Center
Supports the center's operation by setting up appointments, maintaining the cash drawer, posting charges, and assuring the accuracy of patient demographics using the hospital's computer system
Monitor the debit and credit of client accounts
Performs posting operation to institutional clients, and reviews all billing transactions related to accounts receivable system
Resolves client inquires and complaints on institutional billing transactions
Perform order entry, registration, and other clerical duties
Perform the training of all clerical staff in the proper registration and printing of patient reports
Perform other clerical duties as needed which can include insurance verification, recording statistics, registering patients and updating patient accounts
Also assists with scheduling patient appointments, answers phones and inform patients of their benefits
Also, complete other duties as needed

Fulltime

New

Vice President of Clinical Reimbursement / MDS

Vice President of Clinical Reimbursement / MDS at Azria Health. Azria Health is ...

Location

United States , Des Moines

Salary:

Not provided

Azria Health Longview

Expiration Date

Until further notice

Requirements

Active RN license required
multistate licensure preferred
Minimum of 5 years of experience in long-term care reimbursement and MDS leadership
Multi-facility oversight experience strongly preferred
Extensive knowledge of PDPM, Medicare, Medicaid, OBRA regulations, and CMS guidelines
Proven ability to analyze financial and clinical data to drive operational outcomes
Strong leadership, communication, organizational, and problem-solving skills
Ability to travel regularly throughout Iowa and Kansas facilities
RAC-CT, RAC-CTA, or other reimbursement-related certifications preferred

Job Responsibility

Provide strategic oversight and leadership for all MDS and clinical reimbursement operations across multiple skilled nursing facilities
Ensure accuracy, timeliness, and compliance of MDS assessments and reimbursement processes
Lead and support regional and facility MDS coordinators and reimbursement teams
Monitor and optimize Medicare and Medicaid reimbursement performance under PDPM and state-specific reimbursement methodologies
Analyze reimbursement trends, case mix indices, quality measures, and financial outcomes to identify opportunities for improvement
Develop and implement policies, procedures, and best practices related to clinical reimbursement and MDS operations
Ensure compliance with all federal and state regulations, CMS guidelines, and company standards
Partner with clinical, operational, and financial leadership to improve documentation accuracy and reimbursement integrity
Conduct audits and provide education, training, and mentorship to facility teams
Assist facilities during surveys, audits, appeals, and regulatory reviews related to reimbursement and documentation

What we offer

Health, dental, and vision insurance
Paid time off
Retirement plan options
Professional development opportunities
Supportive and collaborative leadership environment

Fulltime

New

Director Patient Care

As our Director of Patient Care, you will be responsible for providing strategic...

Location

United States , Bryan

Salary:

49.54 - 73.70 USD / Hour

American Nursing Care

Expiration Date

Until further notice

Requirements

Bachelors Of Science Nursing and Four (4) years of nursing experience in a tertiary acute care hospital
Masters Nursing, MBA, or MHA (Internal candidates are required to complete Master’s program within 3 years) and five (5) years of management experience at the nurse manager level or above
Excellent clinical and operational skills
Registered Diagnostic Cardiac Sonographer
Registered Nurse: TX
Basic Life Support - CPR
Advanced Cardiac Life Support

Job Responsibility

Providing strategic and operational leadership for specific patient care units or services
Managing, mentoring, and developing nursing staff
Overseeing patient safety initiatives
Ensuring regulatory compliance
Optimizing clinical workflows to enhance patient outcomes and satisfaction
Monitoring metrics to validate performance against national and system benchmarks
Developing leadership within the hospital which supports and maintains excellence in the standards of research based nursing practice
Developing, integrating, and implementing goals of the hospital and nursing into their service line(s)
Leading quality programs and working to develop action plans for continuous improvement
Developing, reviewing, and maintaining fiscal budget within established targets

What we offer

Health/dental/vision
FSA
Matching retirement plans
Paid time off
Tuition assistance
Adoption assistance
Life insurance
401(k)
403(b)

Fulltime

New

Patient Care Assistant II (PCA) - Medical Unit

Rady Children’s nurses serve as local and global leaders in shaping how care is ...

Location

United States , San Diego

Salary:

23.00 - 30.27 USD / Hour

Rady Children's Hospital-San Diego

Expiration Date

Until further notice

Requirements

Proven experience as PCA
Committed to health & safety
Well-organized
Excellent communication and people skills
Positive and conscientious demeanor
Strong ethics
High School Diploma, GED, or Equivalent
BLS for Healthcare Providers issued by the American Heart Association
Must have one of the following: Completion of a Certified Nursing Assistant program
Completion of a Certified Medical Assistant program

Job Responsibility

Under the direct supervision of a licensed care practitioner, the Patient Care Assistant II provides and documents clinical care and associated tasks as assigned
Applies appropriate age and developmental approach in application of care
Regularly performs a supportive role to physicians nurses and families in the delivery of patient care by assisting patient care delivery team with emergency calls and clinical communications and performing admission discharge and transfer workflows
Responds to emergency codes by performing appropriate protocols and identifying, initiating and using vital resources
Prepares and maintains patient medical record on the clinical unit including the medical record discharge process
Enters compiles and reviews reports in a timely and accurate manner
Performs administrative duties as assigned

What we offer

Competitive salaries
Robust benefits
Generous paid time off
Retirement savings with contribution match
Employee recognition
Team Rady events and celebrations
Medical, Dental, Vision
403(b) Retirement Plan
Tuition Reimbursement up to $10,000 per year
Life and Disability Insurance

New

Patient Care Assistant II (PCA) - Medical Unit

Location

United States , San Diego

Salary:

23.00 - 30.27 USD / Hour

Rady Children's Hospital-San Diego

Expiration Date

Until further notice

Requirements

Proven experience as PCA
Committed to health & safety
Well-organized
Excellent communication and people skills
Positive and conscientious demeanor
Strong ethics
High School Diploma, GED, or Equivalent
BLS for Healthcare Providers issued by the American Heart Association
Completion of a Certified Nursing Assistant program
Completion of a Certified Medical Assistant program

Job Responsibility

Under the direct supervision of a licensed care practitioner, provides and documents clinical care and associated tasks as assigned
Applies appropriate age and developmental approach in application of care
Regularly performs a supportive role to physicians nurses and families in the delivery of patient care by assisting patient care delivery team with emergency calls and clinical communications and performing admission discharge and transfer workflows
Responds to emergency codes by performing appropriate protocols and identifying, initiating and using vital resources
Prepares and maintains patient medical record on the clinical unit including the medical record discharge process
Enters compiles and reviews reports in a timely and accurate manner
Performs administrative duties as assigned

What we offer

Competitive salaries
Robust benefits
Generous paid time off
Retirement savings with contribution match
Employee recognition
Team Rady events and celebrations
Medical, Dental, Vision
403(b) Retirement Plan
Tuition Reimbursement up to $10,000 per year
Life and Disability Insurance

Select Country

Initial Clinical Reviewer

Job Description

Job Responsibility

Requirements

Nice to have

Looking for more opportunities?

Initial Clinical Reviewer

Initial Clinical Reviewer

Initial Clinical Reviewer - Remote - AZ

DRG Clinical Dispute Reviewer

Clinic Patient Representative - Gastroenterology

Vice President of Clinical Reimbursement / MDS

Director Patient Care

Patient Care Assistant II (PCA) - Medical Unit

Patient Care Assistant II (PCA) - Medical Unit

Our AI answers in your language