Medical Review Examiner (hybrid)

Awarded 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.

Purpose of the job

• This position will participate in department production/timeliness standards; participate in writing/revising MR Examiner DLP’s (Desk Level Procedures)for Medicare, local and BlueCard; creating job aids to assist all MR Examiner staff: performing quality audits for examiner staff, updating documentation related to workflows; coordinate educational opportunities for the department: work production to maintain inventories and support corporate and regulatory agency requirements.
  
  

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

• High-School Diploma or GED in general field of study
  
  

Required Licenses

• N/A
  
  

Required Certifications

• N/A
  
  

Preferred Qualifications

Preferred Work Experience

• 4 years of experience in claim processing, medical review claims, health insurance, or healthcare related field
• 1 year working as a medical review examiner at a level II or level III capacity
  
  

Preferred Education

• Associate degree in general field of study
  
  

Preferred Licenses

• N/A
  
  

Preferred Certifications

N/A

Essential Job Functions And Responsibilities

• Contribute, maintain and revise desk level policies/procedures annually as directed.
• Address training opportunities resulting from quality audits, introduction of new products or benefits, and new systems
• Identify, research, process, resolve and respond to inquiries and correspondence via telephone, written communication and/or in person.
• Meet quality, quantity and timeliness standards to achieve department performance goals as defined within the department guidelines.
• Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of provider/member inquiries.
• Document and record facts in regard to inquiries and correspondence by updating files and systems.
• Demonstrate and maintain current working knowledge of the required systems, procedures, forms and manuals.
• Perform quality audits for examiner staff and identify further training opportunities
• Keep status of the unit current in accordance with service standards, systems, procedures, forms and manuals through staff meetings and verbal and written communications
• Acts as a resource for assigned staff and other internal customers for medical review related topics
• 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 skill in use of office equipment, including copiers, fax machines, scanner and telephones
• Intermediate PC proficiency
• Intermediate skill in word processing, spreadsheet and database software
• Advanced medical and dental terminology knowledge
  
  

Required Professional Competencies

• Maintain confidentiality and privacy
• 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
• Strong organizational and planning skills; critical thinking skills; ability to work with multiple priorities under limited time constraints
• Set priorities to meet all timeliness standards and goals
• Practice interpersonal and active listening and communications skills to achieve high customer satisfaction with any/all internal and external customers
• Interpret and translate policies, procedures, programs, contracts, benefits and guidelines
• Keep current with the changes/updates to BCBSAZ, including local lines of business, BlueCard & Medicare, accreditation standards and departmental policy changes and revisions.
• Adapt to a changing work environment with flexibility and recognizes potential impact with ability to accentuate the positive to maintain/increase staff morale
  

Required Leadership Experience And Competencies

• Mentor others within the department
• Ability to design and implement strategies that maximize employee potential and foster ethical standards in meeting the organization's mission, vision, and values
  
  

Preferred Competencies

Preferred Job Skills

• Advanced skill in use of office equipment, including copiers, fax machines, scanner and telephones
• Advanced PC proficiency
• Advanced skill in word processing, spreadsheet and database software
  
  

Preferred Professional Competencies

• Knowledge of a wide range of matters pertaining to the organization’s services and operations
• Advanced medical and dental terminology knowledge
• Advanced ability to interpret contract language and benefits
• Advanced claims processing skills
• Advanced knowledge of anatomy and medical practices
• Advanced knowledge and experience using the International Classification of Diseases, Clinical Modification (ICD-CM); Current CPT (Current Procedural Terminology); HCPCS (Healthcare Common Procedure Coding System (HCPCS); DRG (Diagnosis Related Group)
  
  

Preferred Leadership Experience And Competencies

• N/A
  
  

Our Commitment

AZ 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.