Initial Clinical Reviewer - Remote - Arizona

About Blue Cross Blue Shield of Arizona

Recognized as a Healthiest Employer, Blue Cross Blue Shield of Arizona (AZ Blue) pursues its mission to inspire health and simplify health-related decisions. The organization provides diverse health insurance options and services tailored to individuals, families, and businesses of various sizes. AZ Blue also offers tools and information to facilitate informed health choices.

Work Environment and Location Requirements

AZ Blue employs a hybrid workforce model called Workability, allowing flexible work arrangements including hybrid, onsite, and remote positions. Key onsite expectations based on roles include:

• Hybrid People Leaders: must live in Arizona and be onsite at least twice weekly
• Hybrid Individual Contributors: must reside in Arizona (unless otherwise indicated), onsite at least once weekly
• Hybrid Operational Roles: must reside in Arizona (unless otherwise specified), onsite at least once monthly
• Onsite Roles: require daily physical presence based on job requirements
• Remote Roles: no onsite mandate, though leadership may request presence for meetings or training

These requirements may adapt depending on business needs and job duties. This role is a remote opportunity, requiring residence and work within Arizona.

Job Purpose and Responsibilities

• Investigate, process, and resolve inquiries from internal and external customers with a focus on accuracy, confidentiality, compliance, and adaptability within the health insurance context.
• Attend to a variety of health insurance-related customer calls and correspondence daily.
• Review medical records applying medical necessity criteria and benefit plan rules to assess the validity of benefit requests.
• Keep thorough and precise documentation per departmental policies.
• Achieve quality, productivity, and timeliness targets as defined by department guidelines and regulatory standards.
• Provide clear explanations to customers regarding services, benefits, coverage changes, claims, provider networks, and programs.
• Apply plan policies and procedures proficiently.
• Collaborate with internal teams, external plans, healthcare providers, businesses, and governmental bodies for information gathering and problem resolution.
• Support team functions by distributing workload, monitoring tasks, communicating team-related matters to supervisors, and mentoring colleagues as needed.
• Engage in continuing education and keep current with developments in medicine and managed care.
• Comply with standards from State, Federal, and accreditation organizations.
• Maintain a full-time schedule (at least 40 hours/week) with no onsite work required.
• Perform additional duties assigned.

Qualifications

Required Experience: Minimum 2 years in clinical practice, health insurance, or related healthcare fields.

Required Education and Licenses: Associate’s degree or post-high school nursing diploma/certification (e.g., LPN) from an accredited program. Must hold an active, unrestricted license to practice in Arizona as a behavioral health professional (such as LCSW, LPC, LISAC LMFT or licensed psychologist), or nursing license recognized by the Nursing Licensure Compact as RN or Arizona LPN.

Preferred Experience and Education: 3 years of experience and a Bachelor’s degree in nursing or a related discipline.

Preferred Licenses: Active, unrestricted Arizona Registered Nurse license.

Competencies and Skills

• Intermediate computer skills and familiarity with office equipment like scanners, copiers, fax machines, and telephones.
• Strong clinical knowledge and ability to maintain privacy and confidentiality.
• Effective interpersonal communication and active listening to ensure customer satisfaction.
• Ability to write professional correspondence and interpret policies and guidelines.
• Skilled in investigative research and managing data across multiple systems.
• Capability to follow instructions, work independently, collaborate well within a team, and prioritize multiple tasks.
• Good judgment and problem-solving aptitude.
• Conflict resolution and community representation skills.

Preferred Competencies: Advanced computer skills, knowledge of CPT-4 and ICD-9 coding, experience with managed care, utilization management, quality management, and McKesson InterQual® criteria.

Equal Opportunity

AZ Blue is an equal opportunity employer and prohibits discrimination based on race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or other protected categories.