Med Appeals and Grievance Specialist II

PURPOSE OF THE JOB

• Responsible for utilizing clinical acumen and managed care expertise related to researching, resolving and responding to requests for member and provider appeals, grievances, reconsiderations and corrected claims for all lines of business with emphasis on privacy, accuracy, meeting all regulatory and compliance timelines.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

• Level I – 1 year experience in clinical and health insurance or other healthcare related field
• Level II - 3 years experience in clinical and health insurance or other healthcare related field AND 1 year Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
• Level III - 5 years experience in clinical and health insurance or other healthcare related field AND 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
• Level IV - 8 years experience in clinical and health insurance or other healthcare related field AND 3 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)

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) or a compact state as a Registered Nurse (RN), a Physical Therapist (PT) or a Licensed Master Social Worker LMSW. (All Levels)
   

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• Level I – 3 years experience in clinical and health insurance or other healthcare related field
• Level II - 5 years experience in clinical and health insurance or other healthcare related field AND 2 years managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
• Level III – 7 years 5 years experience in clinical and health insurance or other healthcare related field AND 5 years managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
• Level IV – 9 years experience in clinical and health insurance or other healthcare related field AND 5 years above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG)
   

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

• Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
• Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
• Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
• Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration 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.
• 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.
• Attend 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 level one appeals, grievances and corrected claims for local 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.
• Articulate to customers a variety of information about the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, and provider networks.
• 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

Level II

• Ability to demonstrate specialized knowledge to administer Federal Employee Program (FEP)inquiries, appeals, grievances and sub-reconsiderations using appropriate service benefit plan provisions, and internal policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research, and precertification research.
• Ability to demonstrate specialized knowledge to perform reviews for local lines of business, Blue Card Home member appeals and grievances, and Blue Card Host provider grievances. MAG Clinicians also support FEP for member reconsiderations, provider appeals, corrected claims and inquiries.

Level III

• Ability to demonstrate specialized knowledge to complete all Levels of Medical Appeals and Grievance (MAG) cases (Initial internal, voluntary internal and external review appeals and grievances).
• Under minimal direction, lead interdepartmental meetings and oversee special projects as assigned.
• 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.
• Assist in distribution of staff Flow Manager case assignments.
• Identify and recommend process improvements.

Level IV

• Assist in distribution of staff case assignments.
• Under minimal direction, prepare reports and documentation for committee presentation and ad hoc reports as needed.
• Analyze appeals and grievances 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 management and 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. 
• 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).

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