Registered Nurse Coder – DRG Reviewer (Remote) | Blue Cross Blue Shield careers Arizona ID-7579
locationsPhoenixtime typeFull timeposted onPosted 30+ Days Agojob requisition idR4707Awarded a Healthiest Employer Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals families and small and large businesses as well as providing information and tools to help individuals make better health decisions.This is a remote opportunity within and outside the State of Arizona.Purpose of the JobResponsible 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.
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Virtual Assistant, $42/hr, Remote, Weekend, Entry Level
Remote Phone Support, $45/hr, Evening, No Experience Required
Data Entry, No Experience, $50/hr, Remote, College Student
Remote Moderator, $40/hr, Weekend, No Degree, Part-Time
Live Chat Support, Remote, $42/hr, Night Shift, College Student
Phone Job, $50/hr, Remote, No Degree, Part-Time, Weekend
Data Entry, $45/hr, Remote, Evening, No Experience Required
Virtual Assistant, No Experience, $42/hr, Remote, Part-Time
Remote Customer Support, $50/hr, Night Shift, No Degree
Remote Data Entry, $40/hr, College Student Friendly, Part-Time
Live Chat Support, $42/hr, Weekend, Remote, No Degree
Virtual Assistant, Remote, $45/hr, Evening, No Experience
Remote Phone Job, $50/hr, College Student, Night Shift
Remote Moderator, $42/hr, Weekend, No Experience Required
Data Entry, No Degree, $45/hr, Part-Time, Remote Job
Customer Support, $50/hr, Remote, Evening/Night Job, No Degree
Virtual Assistant, $42/hr, Remote, Weekend, No Degree
Remote Live Chat, $45/hr, College Student, No Experience
Remote Data Entry, $40/hr, Part-Time, No Degree Required
Phone Support, $50/hr, Weekend, Remote, No Experience
Virtual Assistant, $42/hr, Evening, Remote, No Degree
Remote Customer Support, $45/hr, No Experience, Part-Time
Data Entry, $50/hr, Night Job, No Degree, Remote
Remote Moderator, $40/hr, College Student Friendly, Part-Time
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QualificationsREQUIRED QUALIFICATIONSRequired Work ExperienceExperience in clinical and health insurance or other healthcare related fieldLevel 1 – 1 yearLevel 2 – 3 yearsLevel 3 – 5 yearsLevel 4 – 8 yearsManaged 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 yearsLevel 3 – 2 yearsAbove 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 yearsRequired EducationAssociates Degree in a healthcare field of study or Nursing Diploma (Applies to All Levels) Required LicensesActive current and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN).Required CertificationsCertified Medical CoderPREFERRED QUALIFICATIONSPreferred Work ExperienceExperience in clinical and health insurance or other healthcare related fieldLevel 1 – 3 yearsLevel 2 – 5 yearsLevel 3 – 7 yearsLevel 4 – 9 yearsManaged 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 yearsLevel 3 – 5 yearsAbove 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 yearsPreferred EducationBachelor’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 LicensesActive current and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN).Preferred CertificationsCertified Medical Coder Essential Job Functions and Responsibilities Level IPerform 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 projectsAttend 1:1s 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 emotionalMaintaining Return on Investment (ROI) trackingOther duties as assigned (HEDIS Quality improvement outreach)level IIAbility to demonstrate specialized knowledge to do in-depth research and provide accurate written documentationPrepare and deliver reports and documentation for committee presentation and ad hoc reports as needed.Maintaining Return on Investment (ROI) trackinglevel IIIPrepare 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 managementlevel IVDevelopment and maintenance of Special Medical Projects Program Description policies desk level procedures and job aidsUnder minimal direction develop and maintain Return on Investment (ROI) tracking and prepare summary presentation to appropriate committees and leadership ad hocUnder 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 managements absence.Maintain a working knowledge of all activities in the department and provide assistance to departmental staff and interdepartmental staff as necessary. ALL LEVELSEach 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 assignedCompetenciesREQUIRED COMPETENCIESRequired Job SkillsIntermediate PC proficiency (All Levels)Intermediate skill using office equipment including copiers fax machines scanner and telephones (All Levels)Required Professional CompetenciesMaintain confidentiality and privacyAdvanced clinical knowledgePractice interpersonal and active listening skills to achieve customer satisfactionCompose a variety of business correspondenceInterpret and translate policies procedures programs and guidelinesCapable of investigative and analytical researchNavigate gather input and maintain data records in multiple system applicationsFollow and accept instruction and directionEstablish and maintain working relationships in a collaborative team environmentOrganizational skills with the ability to prioritize tasks and work with multiple priorities under limited time constraintsIndependent and sound judgment with good problem solving skillsAbility to assist in training of new and existing staff (Applies to Levels 3 and 4)Required Leadership Experience and CompetenciesAbility to revise departmental policies and procedures and desk levels as well as develop new policies and procedures and desk levels as needed (Applies to Levels 3 and 4)Proven leadership and assistance through positive reinforcement of processes and company policies(Applies to Levels 3 and 4.)Independently coordinates with internal audit corporate integrity and other departments as needed to complete projectsPREFERRED COMPETENCIESPreferred Job SkillsAdvanced PC proficiencyKnowledge of Current CPT ICD- 9 ICD-10 HCPCS and DRG codingClaims processingEnd to end researchPreferred Professional CompetenciesWorking knowledge of McKesson InterQual® criteria and Medical Coverage Guidelines/Medical PoliciesAdvanced ability to interpret contract language and benefitsPreferred Leadership Experience and CompetenciesUnder minimal direction prepare and deliver reports and documentation for committee presentation and ad hoc reports as needed.Our CommitmentAZ Blue does not discriminate in hiring or employment on the basis of race ethnicity color religion sex sexual orientation gender identity national origin age disability protected veteran status or any other protected group.Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company see azblue.com. If interested in this position please apply.
