BCBSAZ
RN Med Policy Development/Research Specialist (UM experience) - REMOTE-AZ
AZ Blue Phoenix, AZ 85021 · Full-time
Sponsorship not specifiedDetected 30 days ago
Code ReviewCustomer SupportResearchLeadershipProblem SolvingMentoringOrganizational Skills
About the role
- Our positions are classified as hybrid, onsite or remote.
- This remote work opportunity requires residency, and work to be performed, within the State of Arizona.
Responsibilities
- With moderate assistance and review by management, perform basic level of code review
- Responsible for the training, development and support of grade level I staff under an established training program
- Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements
- Responsible for the training, development and support of grade level I and II staff under an established training program
- Responsible for the training, development and support of grade level III staff under an established training program
- Each progressive level includes the ability to perform the essential functions of any lower levels.
- Perform all other duties as assigned.
Requirements
- Associate's Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program (Applies to All Levels)
- Required Work Experience
- Required Licenses
- Required Certifications
- 2 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All 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
- Active, current, 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 All Levels)
- 3 year(s) of experience in clinical field of practice, health insurance, or other health care related field (All Levels)
Nice to have
- 1 year(s) of experience in claims retrospective review, utilization management, case management, appeals and grievances or quality review field (Applies to All Levels)
- Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
- Active, current, and unrestricted State of Arizona (a state in the United States) license to practice as a Registered Nurse (Applies to All Levels)
- Preferred Work Experience
- Preferred Licenses
- Preferred Certifications
- Responsible for initiating the consultation and providing a summarization concerning the external review to the requestor.
- 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
Compensation
- Assist manager with the completion of the monthly, quarterly and annual reporting to Director
- Assist manager with the coordination of all aspects of the annual review(s) of MCG, eviCore and/or Change Healthcare InterQual criteria updates
Benefits
- Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.
- Perform medical technology research related to coverage guidelines and new technology and provide evaluation and summarization to Medical Director Staff and/or Medical Policy Panel
- Perform medical technology research as requested by other areas of BCBSAZ thru the Medical Policy Referral Form
- Develop 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 all 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).
- 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 arrangements for appropriate reimbursement for the consultant's review.
- Communicate medical policy information in protocol format to healthcare providers upon request
- Assist manager with the coordination of all aspects of the Medical Policy Panel and Medical Director Meeting, including preparation, agenda and minutes.
- Assist manager with providing oversight to responsible staff for the monthly review of BCBS Association Medical Policy and Reference Manual (MPRM) updates
- Conduct, and/or participate in internal committees that further the goals of BCBSAZ, the Health Services Division and the Medical Policy & Technology Department
Company info
- 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.