BCBSAZ

Medical Appeals and Grievance (MAG) Specialist II - Remote

AZ Blue Phoenix, AZ 85021 · Mid · Full-time

Sponsorship not specifiedDetected 31 days ago

Customer SupportICD-10ResearchLeadershipCommunicationProblem SolvingOrganizational Skills

About the role

Our positions are classified as hybrid, onsite or remote.
This position is remote within the state of AZ only.
This remote work opportunity requires residency, and work to be performed, within the BCBSAZ Approved states.

Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business
Maintain complete and accurate records per department policy.
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.
Ability to demonstrate specialized knowledge to perform reviews for local lines of business, Blue Card Home member appeals and grievances, and Blue Card Host provider grievances.
MAG Clinicians also support FEP for member reconsiderations, provider appeals, corrected claims and inquiries.
Under minimal direction, lead interdepartmental meetings and oversee special projects as assigned.
Assist in developing new policies and procedures, desk levels, and job aids as needed.
Maintain a working knowledge of all activities in the department and provide assistance to departmental staff and interdepartmental staff as necessary.

Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
Preferred Work Experience
Preferred Licenses
Preferred Certifications
Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication.
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.
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.

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, W

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.
Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis.
Participate in continuing education and current developments in the fields of medicine and managed care.
Articulate to customers a variety of information about the organization's services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, and provider networks.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeal, grievance and reconsideration requests.
Ability to demonstrate specialized knowledge to complete all Levels of Medical Appeals and Grievance (MAG) cases (Initial internal, voluntary internal and external review appeals and grievances).
Initiate, develop and implement in-service educational presentations.

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, emotional
At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work.

This listing is sourced directly from BCBSAZ's careers page and normalized into a canonical job model.