Registered Nurse Coder - DRG Reviewer (Remote)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make 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 make better health decisions.

This is a remote opportunity within and outside the State of Arizona.

Purpose of the Job

• Responsible for utilizing clinical acumen, medical coding, and managed care expertise related to researching, resolving and recouping pre- and post-payment over utilization, fraud, waste and abuse. Works independently with senior leaders and Medical Directors.  Maintains emphasis on privacy, accuracy, meeting all regulatory and compliance timelines.

Qualifications

REQUIRED QUALIFICATIONS

Required Work Experience

Experience in clinical and health insurance or other healthcare related field

Level 1 - 1 year

Level 2 - 3 years

Level 3 - 5 years

Level 4 - 8 years

Managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievances (MAG)

Level 2 - 1 years

Level 3 - 2 years

Above satisfactory job performance in the managed care environment with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievance (MAG)

Level 4 - 3 years

Required Education

• Associate’s Degree in a healthcare field of study or Nursing Diploma (Applies to All Levels)
   

Required Licenses

• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN).

Required Certifications

• Certified Medical Coder

PREFERRED QUALIFICATIONS

Preferred Work Experience

Experience in clinical and health insurance or other healthcare related field

Level 1 - 3 years

Level 2 - 5 years

Level 3 - 7 years

Level 4 - 9 years

Managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management, and/or Medical Appeals and Grievances (MAG)

Level 2 - 2 years

Level 3 - 5 years

Above satisfactory job performance in the managed care environment with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Medical Review, Case Management and/or Medical Appeals and Grievances (MAG)

Level 4 - 5 years

Preferred Education

• Bachelor's Degree in Nursing or related field of study (Applies to All Levels)
• Masters Degree in Nursing or related field of study (Applies to All Levels)

Preferred Licenses

• Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN).

Preferred Certifications

• Certified Medical Coder

Essential Job Functions and Responsibilities

Level I

• Perform in-depth analysis, clinical review and resolution of provider pre and post payment claims as related to medical coverage guidelines and community standards.
• Reviews and prepares internal audit cases for Medical Directors.
• Identify, research, process, resolve and respond to Sr. Medical Director  inquiries primarily through written / verbal communication.
• Respond to a diverse and high volume of claims projects.
• Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of billing and charges.
• Maintain complete and accurate records per BCBSAZ policy.
• Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
• 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 large scale projects
• Attend 1:1’s, staff and interdepartmental meetings.
• Participate in continuing education and current developments in the fields of medicine and managed care.
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