REMOTE Clinical Reviewer-Prior BHUM & Managed Care experience

• 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. This job description is primary for utilization management functions but can assist with care management if a business need arises.

REQUIRED QUALIFICATIONS

Required Work Experience

• 2 year(s) of experience in clinical field of practice, health insurance, or other health care related field

Required Education

• Associates Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program or Masters Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D. ?

Required Licenses

• 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

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

• 3 year(s) of experience in clinical field of practice, health insurance, or other health care related field
• 1-2 year (s) of experience working in a managed care organization

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

Preferred Certifications

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

• 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, behavioral health and managed care at least annually.
• 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.