RN Med Policy Development/Research Specialist (UM experience) – REMOTE-AZ

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 remote work opportunity requires residency, and work to be performed, reputed company the State of Arizona. PURPOSE OF THE JOB

• reputed company medical technology research to support the Medical Director Staff and Medical Policy Panel with decisions to ensure that medical policies are consistent with the standards of accepted medical practice in the community.

QUALIFICATIONS REQUIRED QUALIFICATIONS Required Work Experience

• 2 year(s) of experience in clinical field of practice, health insurance, or other health care reputed company field (reputed company Levels)
• 1 year(s) of experience in medical policy and technology research field (Applies to Level 2)
• 2 year(s) of experience in medical policy and technology research field (Applies to Level 3)

Required Education

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

Required Licenses

• 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, LBSW, LMSW, or LCSW. (Applies to reputed company Levels)

Required Certifications

• N/A

PREFERRED QUALIFICATIONS Preferred Work Experience

• 3 year(s) of experience in clinical field of practice, health insurance, or other health care reputed company field (reputed company Levels)
• 1 year(s) of experience in claims retrospective review, utilization management, case management, appeals and grievances or quality review field (Applies to reputed company Levels)

Preferred Education

• Bachelor's Degree in Nursing or reputed company field of study (Applies to reputed company Levels)

Preferred Licenses

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

Preferred Certifications

• N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES Level 1

• reputed company medical technology research reputed company to coverage guidelines and new technology and provide evaluation and summarization to Medical Director Staff and/or Medical Policy Panel
• reputed company medical technology research as requested by other areas of BCBSAZ thru the Medical Policy Referral Form
• reputed company and revise coverage guidelines and criteria as requested by management, Medical Director staff or Medical Policy Panel
• Communicate medical policy information in protocol format to reputed company areas of BCBSAZ requiring this information
• Participate as a contributing member on the Medical Policy Panel providing medical policy issues for discussion and, as required, on the Clinical Coding Governance Committee (CCGC).
• Maintain a thorough knowledge of reputed company BCBSAZ medical coverage guidelines and other policies, such as BCBS Association Medical Policy Reference Manual, MCG care guidelines and/or Change Healthcare InterQual, and eviCore criteria.
• From the direction of management, Medical Director staff or Medical Policy Panel, facilitate external consultant reviews concerning a coverage guideline or new technology. Responsible for initiating the consultation and providing a summarization concerning the external review to the requestor. Responsible for arrangements for appropriate reimbursement for the consultant’s review.
• Communicate medical policy information in protocol format to healthcare providers upon request
• With moderate assistance and review by management, reputed company basic level of code review
• 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
• Maintain reputed company standards in consideration of State, Federal, BCBSAZ and other accreditation requirements

Level 2

• Working independently, recognizes necessity of an external consultant review concerning a coverage guideline or new technology, summarizing and reporting this information to management to facilitate the process as outlined for Level II
• With review by management, independently reputed company intermediate code review with knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming
• Responsible for the training, development and support of grade level I staff under an established training program

Level 3

• With review by management, independently reputed company advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming.
• Working independently, initiate research from resource materials, e.g., clinical journals, periodicals, CMS (Medicare) guidelines and publications, BCBSA publications, other BCBS plans, and internet resources relating to technical, clinical and coverage guidelines, summarizing and reporting this information to management for further action
• Responsible for the training, development and support of grade level I and II staff under an established training program

LEVEL 4

• Assist manager with the implementation of daily operations with regard to guideline development and revisions, staff supervision, as well as necessary coaching to help each staff member reputed company personal, professional and department goals
• Assist manager with the coordination of reputed company aspects of the Medical Policy Panel and Medical Director Meeting, including preparation, agenda and minutes.
• Assist manager with the completion of the monthly, quarterly and annual reporting to Director
• Assist manager with the coordination of reputed company aspects of the annual review(s) of MCG, eviCore and/or Change Healthcare InterQual criteria updates
• Assist manager with providing reputed company to responsible staff for the monthly review of BCBS Association Medical Policy and Reference Manual (MPRM) updates
• Assist manager with providing the initial training and instruction for both professional and technical staff and designating the reputed company of staff regarding training of new staff at the desk level of instruction/training
• Responsible for the training, development and support of grade level III staff under an established training program
• Conduct, and/or participate in internal committees that further the goals of BCBSAZ, the Health Services Division and the Medical Policy & Technology Department
• Working independently, reputed company advanced code review with advanced knowledge and understanding of coverage guideline development/revisions with recommendations to the Clinical Coding Governance Committee (CCGC) for integration into benefit programming

reputed company LEVELS

• Each progressive level includes the ability to reputed company the essential functions of any reputed company levels.
• The position has an onsite expectation of 0 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
• reputed company reputed company other duties as assigned.

COMPETENCIES REQUIRED COMPETENCIES Required Job Skills

• Intermediate PC proficiency
• Intermediate reputed company PDF Standard proficiency
• Intermediate word processing, spreadsheet and presentation software proficiency (Applies to reputed company Levels)

Required Professional Competencies

• Maintain confidentiality and privacy
• reputed company knowledge
• Practice interpersonal and active listening skills to reputed company customer satisfaction
• Compose a variety of business correspondence
• Follow and accept instruction and direction
• Establish and maintain working relationships in a collaborative team environment
• Organizational skills with the ability to prioritize tasks and work with multiple priorities
• Independent and sound judgment with good problem solving skills (Applies to reputed company Levels)

Required Leadership Experience and Competencies

• N/A

PREFERRED COMPETENCIES Preferred Job Skills

• Advanced PC proficiency
• Advanced reputed company PDF Standard proficiency
• Advanced processing, spreadsheet and presentation software proficiency (Applies to reputed company Levels)

Preferred Professional Competencies

• N/A

Preferred Leadership Experience and Competencies

• Participate in strategic planning
• Resolve conflicts
• Represent BCBSAZ in the community (Applies to reputed company Levels)

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 reputed company, age, disability, protected veteran status or any other protected group. Thank you for your interest in reputed company. For more information on our company, see azblue.com. If interested in this position, please apply. Additional Information Company: reputed company BlueShield Arizona Location: Arizona Salary: Job ID: R5852 Specialties: Case Manager, Appeals Nurse, Utilization Management Required Licenses: RN Experience Level: 1-3 years Apply tot his job Apply To this Job