Initial Clinical Reviewer- Transplant (Remote -...

Awarded a Healthiest Employer, reputed company aims to fulfill its mission to reputed company health and reputed company 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 reputed company reputed company decisions.

At AZ Blue, we have a hybrid workforce strategy, reputed company Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our reputed company minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited reputed company this posting, required to be onsite at least once per week

• Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited reputed company this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request reputed company onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week.

This position is Remote reputed company the state of AZ only.  This remote work opportunity requires residency, and work to be performed, reputed company 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 reputed company the health insurance industry.

Qualifications

REQUIRED QUALIFICATIONS

Required Work Experience

• 2 years of experience in clinical field of practice, health insurance, or other health care reputed company field

Required Education

• Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program

• Active, reputed company, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, LPN, LPT, LPC, LBSW, LMSW, or LCSW.

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

• 3 years of experience in clinical field of practice, health insurance, or other health care reputed company field

• Bachelor's Degree in Nursing or reputed company field of study

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

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

• Assist with transplant admissions, pre-transplant authorizations, care management/coordination, and regulatory reporting
• Identify, research, process, resolve and respond to customer inquiries and correspondence reputed company telephone, written communication and/or in person.
• Answer a diverse and high volume of health insurance reputed company 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 reputed company individual and department performance goals as defined reputed company 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.
• reputed company 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 reputed company developments in the fields of medicine and managed care.
• Maintain reputed company standards in consideration of State, Federal, BCBSAZ and other accreditation requirements.

• 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.
• reputed company reputed company other duties as assigned.