Registered Nurse-Medical Review Specialist

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.

REQUIRED QUALIFICATIONS

Required Work Experience

• 2 year(s) of experience in clinical , health insurance or other healthcare related field (Applies to All Levels)

• Completion of two (2) years of BCBSAZ medical review, utilization management, or care management experience (Applies to Level 3)

Required Education

• Associates Degree in general field of study or Post High School Nursing Diploma (Applies to All Levels)

Required Licenses

• Active, current, and unrestricted State of Arizona license to practice as a health professional, including RN, LPT, LBSW, LMSW, or LCSW. (Applies to All Levels)

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 3 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)
• 2 year(s) experience in utilization review, quality assurance, or health insurance industry field (All levels)

Preferred Education

• Bachelor's Degree in Nursing or related field of study (Applies to All Levels)

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

Level I (Grade 27)

• Maintains productivity and accuracy requirements set for this level.
• Demonstrates ability to complete all types of reviews utilizing, but not limited to: appropriate benefit plans, policies, guidelines, claims processing system, member enrollment, provider contracts, BCBSAZ communication records and precertification system.
• Assumes responsibility for in-depth analysis and final resolution of claims requiring clinical review according to department policy, BCBSAZ, State, Federal requirements, as applicable. This may involve coordinating with other BCBSAZ departments.
• Maintains effective communication (verbal and written), both formal and informal with internal and external customers.
• Maintains knowledge of activities in assigned area and possesses the ability to provide assistance as necessary.
• Maintains current knowledge of department policies, medical policy guidelines, benefit plans and utilization criteria for all local lines of business as it relates to the processing of Medical Review claims.
• Analyzes and monitors claims for trends. These trends may illustrate an educational need; need for a referral to a different BCBSAZ department; need for updating a policy / guideline. Makes specific written recommendations to Manager with demonstrated ability to follow through on ideas.
• Accumulates and reports statistics relative to inventory and timeliness. Submits ad hoc reports as necessary. Identifies needs regarding enhancements to systems and/or processes.
• Actively participates on task force(s) as assigned and undertakes and completes special projects.
• Coordinates processing claims resolution with other departments.
• Utilize quality tools in daily interactions and process improvements.
• Positively adapts to a changing work environment with flexibility and recognizes the impact the change will have on the appeal and grievance process.
• Adapts to changing work environment with flexibility and recognizes potential impact with ability to accentuate the positive to maintain/increase staff morale.
• Creates and / or updates departmental Policies and Procedures.
• Participates in continuing education and current developments in fields of managed care; attends courses offered by BCBSAZ Corporate Training and Development Department and the Medical Services Division; participates in appropriate computer-related educational offerings as relates to position function.

Level II (Grade 28)

• Assists in departmental training of new staff and ongoing in-services.
• Assists in revising current policies and procedures and or desk levels, as needed and develops and assists in implementation of new policies and or desk levels.

• Attends and actively participates with interdepartmental teams.
• Takes on special projects as requested by management.

Level III (Grade 29)

• Demonstrates ability, under minimal direction to perform special projects, train new staff, analyze inventory, revise current policies and procedures and or desk levels and develop and implement new policies and or desk levels.
• Initiates, develops and implements ongoing in-services.
• Takes initiative to follow through on issues and identifies opportunities for improvement.

ALL LEVELS

• Each progressive level includes the ability to perform the essential functions of any lower levels.
• 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.