CrawlJobs Logo

Initial Clinical Reviewer

United States, Phoenix · Job Posted May 05, 2026
Apply Position
Job Link Share

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. 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 week; Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week; Hybrid 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 month; Onsite: daily onsite requirement based on the essential functions of the job; Remote: 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 building. Please 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 JOB: 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.

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
  • 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
  • Perform all other duties as assigned

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

Nice to have

  • 3 years of experience in clinical field of practice, health insurance, or other health care related field
  • 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-4 and ICD-9 coding
  • Knowledge of managed care, utilization management, and quality management
  • Working knowledge of McKesson InterQual® criteria

Looking for more opportunities?

Search for other job offers that match your skills and interests.

Similar Jobs for

Initial Clinical Reviewer

8 matching positions

Initial Clinical Reviewer

Responsible for identifying, researching, processing, resolving, and responding ...
Location
Location
United States , Phoenix
Salary
Salary:
Not provided
azblue.com Logo
Blue Cross Blue Shield of Arizona
Expiration Date
Until further notice
Flip Icon
Requirements
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
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
Read More
Arrow Right

DRG Clinical Dispute Reviewer

At Zelis, the DRG Clinical Dispute Reviewer role is responsible for the resoluti...
Location
Location
United States , St. Petersburg; Plano; Boston; St. Louis; Atlanta
Salary
Salary:
95000.00 - 127000.00 USD / Year
zelis.com Logo
Zelis
Expiration Date
Until further notice
Flip Icon
Requirements
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
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
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
Read More
Arrow Right

Clinical Laboratory Scientist

As our Clinical Lab Scientist, you will be a critical diagnostic expert, perform...
Location
Location
United States , San Bernardino
Salary
Salary:
57.77 - 68.68 USD / Hour
americannursingcare.com Logo
American Nursing Care
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • One year experience working as a generalist in an acute hospital clinical laboratory
  • State of California Clinical Laboratory Scientist License
  • Bachelor's Degree in a biological or chemical science as defined by CLIA
Job Responsibility
Job Responsibility
  • Receive and evaluate clinical specimens, ensuring quality and adherence to testing protocols
  • Perform qualitative and quantitative testing following approved policies and procedures
  • Review test results for accuracy, medical relevance, and compliance before releasing reports
  • Communicate critical values promptly and document actions taken
  • Perform quality control, instrument maintenance, and troubleshooting as required
  • Maintain reagent inventory and participate in proficiency surveys
  • Participate in quality improvement initiatives and remain current with departmental updates, policies, and procedures
What we offer
What we offer
  • Medical, prescription drug, dental, vision plans, life insurance, paid time off
  • tuition reimbursement
  • retirement plan benefit(s) including 401(k), 403(b), and other defined benefits offerings
  • Parttime
Read More
Arrow Right
New

Clinical Program Manager

The Clinical Program Manager for CarePoint Blue Sky Neurosciences (CPN) is respo...
Location
Location
United States
Salary
Salary:
90000.00 - 120000.00 USD / Year
carepointhc.com Logo
CarePoint Health
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's degree required
  • Registered Nurse licensure required
  • Two or more years of hospital nursing experience required
  • Two or more years of experience working in clinical operations or program management required
  • Master's degree preferred
  • Inpatient neurology, Neuro ICU, or ED nursing experience preferred
  • Ability to lead and influence teams to ensure delivery of excellent services
  • Ability to apply systems thinking to complex clinical situations
  • Ability to prioritize client needs and conduct root cause analysis for mutually satisfactory solutions
  • Ability to effectively communicate, present, and influence all levels of the organization, including executive and C-level leadership
Job Responsibility
Job Responsibility
  • Direct day-to-day clinical operations for assigned clinical programs and customers to ensure alignment with organizational goals and regulatory standards
  • Represent CPN as the clinical lead for new site implementations including pre-go live program discovery and relationship development, managing clinical aspects of implementations such as protocol alignment, customer readiness, and mock alerts, in collaboration with medical directors
  • Participate in new provider onboarding and monitoring of new provider success according to established key performance indicators (KPIs)
  • Develop and implement standardized protocols, workflows, and care pathways in collaboration with CPN clinical leadership
  • Monitor KPIs for assigned customer systems to evaluate program impact and efficacy
  • Conduct case review process acting as liaison between site clinical leadership and CPN physicians
  • Lead continuous quality improvement initiatives to address gaps in care or clinical workflows
  • Participate in CPN's continuous readiness for Joint Commission accreditation
  • Build and maintain strong, trusted relationships with clinical, operational, and executive stakeholders
  • Represent CPN as the first line of customer engagement throughout the customer life cycle including pre-go live support and relationship management and development
What we offer
What we offer
  • Comprehensive health coverage, including medical, dental, and vision insurance, with access to a Health Savings Account (HSA)
  • Wellbeing and support resources, including an Employee Assistance Program offering confidential counseling and support services
  • Time away from work benefits, featuring accrued paid time off that increases with tenure, along with paid parental leave
  • Financial security and protection, including 401(k) retirement plan with a 7.5% direct employer contribution after 1 year of employment, life insurance, and identity theft protection
  • Community and culture initiatives, including weekly in-office events every Wednesday that foster connection collaboration, and team engagement
  • Fulltime
Read More
Arrow Right
New

Clinical Nurse Specialist, Orthopaedics

Location
Location
Ireland , Lucan
Salary
Salary:
Not provided
hermitageclinic.ie Logo
Blackrock Health Hermitage Clinic
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Be registered in the general division of the Register of Nurses maintained by NMBI
  • Have at least five years recent relevant post-registration nursing experience (full-time or equivalent hours part-time) in an acute hospital setting and a minimum of two years nursing experience in Orthopaedic Nursing
  • Have acquired a level 8 post registration Quality and Qualifications Ireland (QQI), National Framework of Qualifications (NFQ) major academic award relevant to the specialist area- Orthopaedic Nursing (or similar)
Job Responsibility
Job Responsibility
  • Plan and initiate care and treatment modalities within agreed protocols to achieve patient centred outcomes and evaluate their effectiveness
  • Utilize assessment skills and techniques to determine each patient/family needs
  • Plan all care in collaboration with the patient
  • Provide specialist advice to patients on appropriate products to meet their needs
  • Liaise as appropriate with other members of the multidisciplinary team (MDT) regarding any aspect of patient care
  • Develop, document and update care, discharge and teaching plans and documentation as necessary
  • Evaluate the care/information given and reassess accordingly
  • Co-ordinate and track the completion of the patient reported outcome measures (P.R.O.M.S.) at the pre and post-operative assessments, review the patient post-operatively at 6 months, 2 years, 5 years, 10 years, 15 years and 20 years and record any complications in accordance with the Irish National Orthopaedic Register (INOR) template
  • The Orthopaedic CNS will liaise with the consultant surgeon on abnormal clinical issues. This enables better identification and management of patients to improve their experience and outcomes following surgery
  • Monitor and review data input from this hospital. This facilitates multidisciplinary clinical audit, research, assist in developing and leading on best practice
What we offer
What we offer
  • Competitive salary
  • Onsite parking
  • Pension
  • Annual bonus
  • Discounted café
  • Sports and Social club
  • Employee Assistance Programme
  • Discounted onsite pharmacy
  • Fulltime
Read More
Arrow Right
New

Admissions Services Specialist

Acadia Healthcare is seeking remote Admissions Services Specialists to support o...
Location
Location
United States , Franklin
Salary
Salary:
Not provided
acadiahealthcare.com Logo
Acadia Healthcare
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Bachelor's or Master's degree in Behavioral Science, Social Work, Sociology, Nursing, or a related field
  • in some states, RN, LVN/LPN
  • Knowledge of admission/referral processes, techniques, and tools
  • Familiarity with behavioral health issues and services
  • Solid understanding of financial principles and insurance reimbursement practices
  • Knowledge and proficiency with Salesforce.com (or other CRM application), Concur, and MS Office application
  • Licensure, as required for the area of clinical specialty, i.e., RN license, CAC or other clinical counseling or therapy license, as designated by the state in which the facility operates
Job Responsibility
Job Responsibility
  • Manage Referral Management Portals
  • Monitor all faxed referrals
  • Monitor all webforms and call center handoffs/rollover referrals
  • Utilize facility admissions/exclusionary criteria to process incoming types of referrals
  • Respond to inquiries about the facility within facility policy timeframes
  • Document calls inside of Salesforce and follow-up as needed
  • Complete Prior Authorization
  • Pre-Admit the patients in billing system
  • Coordinate with local admissions department regarding bed availability
  • Facilitate intake, admissions, and utilization review process for incoming patients
  • Fulltime
Read More
Arrow Right
New

Customer Success Leader

As the Customer Success Manager, you will serve as the strategic partner and pri...
Location
Location
United States , Raleigh
Salary
Salary:
104000.00 - 143000.00 USD / Year
https://www.baxter.com/ Logo
Baxter
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • A bachelor's degree in business, healthcare, IT, management, or a related field
  • 5+ years of experience in business, customer relationship management, sales, or service roles preferred
  • A proactive, detail-oriented mindset with strong critical-thinking and problem-solving skills
  • Leadership presence and integrity with the ability to lead communications, meetings, and customer-facing initiatives
  • Strong analytical and communication skills to simplify complex issues and present them clearly
  • Exceptional customer service orientation with strong interpersonal and documentation capabilities
  • Ability to travel up to 50% for planned and unplanned customer needs
  • A commitment to Baxter's values of Passion, Respect, Integrity, and Innovation
  • Applicants must be authorized to work for any employer in the U.S. We are unable to sponsor or take over sponsorship of an employment visa at this time.
Job Responsibility
Job Responsibility
  • Owning customer relationships by driving adoption, retention, satisfaction, and long-term value across assigned accounts
  • Building trusted advisor partnerships with customer stakeholders and guiding them toward full utilization of Baxter solutions
  • Preparing customers for advocacy through ongoing engagement, value realization, and strategic communication
  • Coordinating cross-functional issue resolution to ensure timely, effective outcomes and a seamless customer experience
  • Leading customer relationship initiatives including success planning, business reviews, and proactive health checks
  • Managing escalations and communication while keeping sales and internal stakeholders aligned and informed
  • Educating customers on new features by initiating upgrades, reviewing release notes, and coordinating training
  • Capturing the voice of the customer to drive continuous improvement and inform future service offerings
What we offer
What we offer
  • medical and dental coverage that start on day one
  • insurance coverage for basic life, accident, short-term and long-term disability, and business travel accident insurance
  • Employee Stock Purchase Plan (ESPP), with the ability to purchase company stock at a discount
  • 401(k) Retirement Savings Plan (RSP), with options for employee contributions and company matching
  • Flexible Spending Accounts
  • educational assistance programs
  • time-off benefits such as paid holidays, paid time off ranging from 20 to 35 days based on length of service
  • family and medical leaves of absence
  • paid parental leave
  • commuting benefits
  • Fulltime
Read More
Arrow Right
New

Nurse Manager

Westside Family Healthcare is a nonprofit organization that provides high qualit...
Location
Location
United States , Dover
Salary
Salary:
Not provided
westsidehealth.org Logo
Westside Family Healthcare Inc
Expiration Date
Until further notice
Flip Icon
Requirements
Requirements
  • Active RN licensure in the State of Delaware with no restrictions
  • Five years’ experience as a RN
  • Two years' supervisory experience
  • Current BLS certification
Job Responsibility
Job Responsibility
  • Provide leadership and support to site clinical operations team including nurses and Medical Assistants (MAs) including maintaining team schedules to ensure adequate coverage, completing performance reviews, coordination of educational and preceptor opportunities for nursing students, and participating in the recruitment of new nurses and MAs
  • Participate in recurring meetings with Associate Director of Clinical Operations and any other meetings at the request of the Associate Director of Clinical Operations
  • Participate in the development of clinical policies, procedures, workflow, and staff development. Provide support with education and implementation of workflow changes resulting from the addition or revision of policies and processes
  • Evaluate outcomes of care coordination efforts by measuring interventions effectiveness and fostering a continuous improvement mentality
  • Oversee the daily huddle in collaboration with Nurse Supervisor and/or Lead/Clinical Floor Supervisor(s) to oversee the flow of clinical care as related to assigned care team, including identifying patients’ needs and care gaps
  • Lead quality improvement activities and initiatives
  • Provide ambulatory care support as a member of the care team, as needed
  • Advocate for patients by working with the providers and auxiliary staff to ensure the patients’ needs are met
  • Provide support for other Nurse Managers including covering sites in the event of a staffing issue or managerial support
  • Completes the responsibilities of the Nurse Supervisor if this position is not filled at a site
What we offer
What we offer
  • Medical insurance (two plans to choose from)
  • Dental insurance (through Guardian Dental)
  • Vision insurance
  • Life insurance paid by Westside with the option to purchase more
  • Short term disability paid for by Westside
  • Long term disability paid by the employee
  • 401(k) retirement plan with a match
  • Supplemental insurances
  • Generous PTO package
  • Flexibility to provide work/life balance
  • Fulltime
Read More
Arrow Right