Registered Nurse-Initial Clinical Reviewer 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.

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
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 5 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 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
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
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
Resolve conflicts
Represent BCBSAZ in the community

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

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Registered Nurse-Initial Clinical Reviewer

Job Description

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