BH UM Clinical Reviewer- Remote AZ

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

Qualifications

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

• Associate’s Degree in general field of study or Post High School Nursing Diploma or Master’s 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.

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
• 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

• 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 daily.
• 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, 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.

competencies

REQUIRED COMPETENCIES

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

PREFERRED COMPETENCIES

Preferred Job Skills

• Advanced PC proficiency

• Knowledge of CPT 2018 and ICD-10 coding

Preferred Professional Competencies

• Knowledge of managed care, utilization management, and quality management
• Working knowledge of McKesson InterQual criteria, MCG, ASAM, or other nationally recognized criteria

Preferred Leadership Experience and Competencies

• N/A