Purpose of the Job

• Responsible for utilizing clinical acumen, medical coding, and managed care expertise related to researching, resolving and recouping pre- and post-payment over utilization, fraud, waste and abuse. Works independently with senior leaders and Medical Directors.  Maintains emphasis on privacy, accuracy, meeting all regulatory and compliance timelines.

Qualifications

REQUIRED QUALIFICATIONS

Required Work Experience

Experience in clinical and health insurance or other healthcare related field

Level 1 - 1 year

Level 2 - 3 years

Level 3 - 5 years

Level 4 - 8 years

Managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievances (MAG)

Level 2 - 1 years

Level 3 - 2 years

Above satisfactory job performance in the managed care environment with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievance (MAG)

Level 4 - 3 years

Required Education

• Associate’s Degree in a healthcare field of study or Nursing Diploma (Applies to All Levels)
   

Required Licenses

• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN).

Required Certifications

• Certified Medical Coder

PREFERRED QUALIFICATIONS

Preferred Work Experience

Experience in clinical and health insurance or other healthcare related field

Level 1 - 3 years

Level 2 - 5 years

Level 3 - 7 years

Level 4 - 9 years

Managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievances (MAG)

Level 2 - 2 years

Level 3 - 5 years

Above satisfactory job performance in the managed care environment with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management and/or Medical Appeals and Grievances (MAG)

Level 4 - 5 years

Preferred Education

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

Preferred Licenses

• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN).

Preferred Certifications

• Certified Medical Coder

Essential Job Functions and Responsibilities

Level I

• Perform in-depth analysis, clinical review and resolution of provider pre and post payment claims as related to medical coverage guidelines and community standards.
• Reviews and prepares internal audit cases for Medical Directors.
• Identify, research, process, resolve and respond to Sr. Medical Director  inquiries primarily through written / verbal communication.
• Respond to a diverse and high volume of claims projects.
• Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of billing and charges.
• Maintain complete and accurate records per BCBSAZ policy.
• Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
• 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 large scale projects
• Attend 1:1’s, staff and interdepartmental meetings.
• 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.
• Maintain productivity and accuracy goals based on regulatory requirements, accreditation standards, and service level agreements.
• Demonstrate ability to acquire specialized knowledge to complete all types of projects for all  lines of business using appropriate benefit plan booklet, administrative guidelines and policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research and precertification research.
• Adheres to BCBSAZ brand promise of being a “Trusted Advisor” by walking in the customers shoes including processing work using the principles of easy, effective, emotional
• Maintaining Return on Investment (ROI) tracking
• Other duties as assigned (HEDIS, Quality improvement, outreach)

level II

• Ability to demonstrate specialized knowledge to do in-depth research and provide accurate written documentation
• Prepare  and deliver reports and documentation for committee presentation and ad hoc reports as needed.
• Maintaining Return on Investment (ROI) tracking

level III

• Prepare  and deliver reports and documentation for committee presentation and ad hoc reports as needed.
• Assist in developing new policies and procedures, desk levels, and job aids as needed.
• Assist in training new staff and provide ongoing training for existing staff as needed.
• Identify and recommend process improvements.
• Maintain Return on Investment (ROI) tracking and prepare ROI summary as directed by management

level IV

• Development  and maintenance of Special Medical Projects Program Description, policies, desk level procedures and job aids
• Under minimal direction develop and maintain Return on Investment (ROI) tracking and prepare summary presentation to appropriate committees and leadership ad hoc
• Under minimal direction, prepare  and deliver reports and documentation for committee presentation and ad hoc reports as needed.
• Analyze special project  data and make recommendations based on trends identified.
• Take initiative to follow through on issues and opportunities for process improvements.
• Initiate, develop and implement in-service educational presentations.
• Work collaboratively with Senior Medical Directors and management, provide leadership for the department in day to day activities as well as in management’s absence.
• Maintain a working knowledge of all activities in the department and provide assistance to departmental staff and interdepartmental staff as necessary. 

ALL LEVELS

• Each progressive level includes the ability to perform the essential functions of any lower levels.
• Consistently demonstrate alignment with the BCBSAZ “Living our Values” culture by participating in annual, community service campaigns and/or projects such as, CARES Club, United Way and/or community wellness initiatives (Walk for Hope, Walk to Stop Diabetes, Phoenix Heart Walk, etc.).
• 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