Registered Nurse-Initial Clinical Reviewer - Commercial Prior Auth
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 organizations 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
Associates 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
Our Commitment
AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
Apply Now
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 organizations 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
Associates 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
Our Commitment
AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
Apply Now