Initial Clinical Reviewer- RN (Remote - AZ)

Blue Cross ® Blue Shield ® of Arizona (AZ Blue) is committed to helping Arizonans get healthier faster and stay healthier longer. With a mission to inspire health and make it easy, AZ Blue offers health insurance and related services to more than 2 million customers. AZ Blue, a non-profit company, is an independent licensee of the Blue Cross Blue Shield Association. The company and its subsidiaries employ more than 3,200 people in its Phoenix, Flagstaff, and Tucson offices.

This position is Remote within the state of AZ only. This remote work opportunity requires residency, and work to be performed, within the State of Arizona. 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.

Assist with transplant admissions, pre-transplant authorizations, care management/coordination, and regulatory reporting 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 and managed care. Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements The position has an expectation of 5 days per week and 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.