• Performing research and processing of appeals, grievances, corrected claims, medical records and related correspondence in accordance with BCBSAZ, State, Federal and other accreditation requirements as applicable.

REQUIRED QUALIFICATIONS

Required Work Experience

• 1 years of experience in claims processing, medical/ pharmacy precertification, appeals and grievances coordination or other applicable related work experience(Applies to All Levels)

Required Education

• High-School Diploma (Applies to All Levels) or higher

Required Licenses

• N/A

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

• 2 years of experience in a lead or senior claims role (Applies to All Levels)
• 3 years of experience in claims processing and correspondence with multiple claims systems (All Levels)
• 2 years of experience in the medical or healthcare related field (Applies to All Levels)
• 3 years as a pharmacy technician or precertification technician

• Bachelor's degree in business/healthcare or related field

• N/A

• Certified Coder

Level 1

• Perform analysis and research of requests received for medical grievances, appeals for final resolution or referral to the Clinical Medical Appeals and Grievance (MAG) Staff.
• Maintains advanced end user knowledge of multiple systems including vendor medical management and claims systems
• Conduct research to resolve requests received from members, providers and other Blue Plans in accordance with State, Federal, BlueCard and URAC timeliness standards.
• Review medical records to determine if records satisfy the requested or supporting information required.
• Complete specific Appeals and Grievances after clinical training.
• Maintain current medical terminology knowledge.
• Identify research and assemble medical records, coverage guidelines, claims and historical data for MAG staff review and presentation to the Medical Director, Department of Insurance, Executive Inquiries or other legal proceedings.
• Perform data corrections and initiate adjustments related to appeals originating from the Medical Grievance and Appeals Department. Communicate decisions through appropriate system updates.
• Analyze and monitor appeals, grievances, and insufficient records to identify possible trends or patterns and document and report findings to Supervisor and/or Manager with suggestions and follow-up.
• Assist in utilization studies and analysis.
• Meet department and individual contributor goals.
• Performs activities with limited supervision.
• Use pharmacy system to research and prepare level 2 and external pharmacy cases
• Monitor proxy box for pharmacy appeals and grievances
• Monitors Appeals and Grievance Coordination (AGC) proxy boxes and phones as assigned
• Demonstrates commitment to excellent customer experience.
• Maintain understanding and working knowledge of a variety of lines of business including fully insured, self-funded groups, Affordable Care Act individuals and groups, and Blue Card
• Maintain understanding of Medical Management and claims processing systems
• Process records/document requests related to appeals and grievances
• Works with vendors and special groups to ensure appropriate communication between levels of appeals including sending required documentation to group/vendor contact
• Researches and reopens claims appeals for diagnosis mismatch
• Researches and communicates with legal team as directed by leadership, including assisting with written communication
• Attest to training competency related to medical terminology and new/revised processes
• Ensure HIPAA compliance/PHI privacy
• Communicates with privacy office as indicated related to CMS1557 discrimination grievance requests
• Assists with research and preparation of appeals files for accreditation site visits
• Completes mandatory training and 3 or more additional training courses
• Completes IDP and participates in Perceptyx action plan
• Maintain current knowledge and understanding of State, Federal, BCBSAZ, Blue Card, and accreditation requirements as applicable, pertaining to appeal and grievance timeframes, processing, tracking, analysis and reporting to ensure case reviews are completed accurately and timely.
• Other duties as assigned

Level 2

• Perform Level 1-2 activities independently.
• Identify and report trends seen in grievances, appeals, and medical records to management.
• Assist Claims Department with customer inquiries.
• Assist with questions and training for Level 1 Reviewers.
• Perform focused quality sampling audits and report findings to management.
• Attend Blue Cross Blue Shield Association appeals and grievance roundtable meetings as assigned
• Assist with working aging report as assigned
• Assist with case assignment as assigned

Level 3

• Perform Level 1-3 activities independently.
• Initiate adjustments at time of final determination or coordinate with appropriate department for resolution.
• Process Blue Card requests.
• Participate on special teams and projects as needed, related to claims, recoupments, coding related to medical coverage guidelines
• Create job aids and assist to maintain desk level procedures.
• Provide training and mentoring of staff.
• Perform focused quality sampling audits and report findings to management.
• Conduct Timely Filing reviews for Level 2 requests.
• Perform User Acceptance Testing (UAT) for system upgrades

All levels

• Each progressive level includes the ability to perform the essential functions of any lower levels.
• 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.
• Perform all other duties as assigned.