Medical Review Specialist- Registered Nurse
Blue Cross Blue Shield of Arizona 17 reviews - Phoenix, AZ

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Blue Cross Blue Shield of Arizona is a local, independent and not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,300 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.

Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering 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.

Position Details

Identifying, researching, processing, resolving and responding to inquiries from internal and external customers with emphasis on excellence, privacy, compliance and versatility within the health insurance industry.

Maintains productivity and accuracy requirements set for this level.

Demonstrates ability to complete all types of reviews utilizing, but not limited to: appropriate benefit plans, policies, guidelines, claims processing system, member enrollment, provider contracts, BCBSAZ communication records and precertification system.

Assumes responsibility for in-depth analysis and final resolution of claims requiring clinical review according to department policy, BCBSAZ, State, Federal requirements, as applicable. This may involve coordinating with other BCBSAZ departments.

Maintains effective communication (verbal and written), both formal and informal with internal and external customers.

Maintains knowledge of activities in assigned area and possesses the ability to provide assistance as necessary.

Maintains current knowledge of department policies, medical policy guidelines, benefit plans and utilization criteria for all local lines of business as it relates to the processing of Medical Review claims.

Analyzes and monitors claims for trends. These trends may illustrate an educational need; need for a referral to a different BCBSAZ department; need for updating a policy / guideline. Makes specific written recommendations to Manager with demonstrated ability to follow through on ideas.

Accumulates and reports statistics relative to inventory and timeliness. Submits ad hoc reports as necessary. Identifies needs regarding enhancements to systems and/or processes.

Actively participates on task force(s) as assigned and undertakes and completes special projects.

Coordinates processing claims resolution with other departments.

Utilize quality tools in daily interactions and process improvements.

Positively adapts to a changing work environment with flexibility and recognizes the impact the change will have on the appeal and grievance process.

Adapts to changing work environment with flexibility and recognizes potential impact with ability to accentuate the positive to maintain/increase staff morale.

Creates and / or updates departmental Policies and Procedures.

Participates in continuing education and current developments in fields of managed care; attends courses offered by BCBSAZ Corporate Training and Development Department and the Medical Services Division; participates in appropriate computer-related educational offerings as relates to position function.

Employment Requirements

Required Work Experience

2 year(s) of experience in clinical , health insurance or other healthcare related field (Applies to All Levels)

Required Education

Associate¿s Degree in general field of study or Post High School Nursing Diploma

Required Licenses

Active, current, and unrestricted Registered Nurse State of Arizona license to practice Preferred

Work Experience

3 year(s) of experience in clinical field of practice, health insurance, or other health care related field

2 year(s) experience in utilization review, quality assurance, or health insurance industry field

Preferred Education

Bachelor's Degree in Nursing or related field of study

Required Job Skills

¿Intermediate PC proficiency

¿Intermediate skill using office equipment, including copiers, fax machines, scanner and telephones (All Levels)

Required Professional Competencies

¿Maintain confidentiality and privacy

¿Strong current clinical knowledge

¿Practice interpersonal and active listening skills to achieve customer satisfaction

¿Compose a variety of business correspondence

¿Interpret and translate policies, procedures, programs and guidelines

¿Capable of investigative and analytical research

¿Navigate, gather, input and maintain data records in multiple system applications

¿Follow and accept instruction and direction

¿Establish and maintain working relationships in a collaborative team environment

¿Organizational skills with the ability to prioritize tasks and work with multiple priorities

¿Independent and sound judgment with good problem solving skills (Applies to All Levels)

¿Analyzes and interprets and makes recommendations based on appeals data and trends

Comply with BCBSAZ corporate and departmental policies and procedures, including, but not limited to Code Blue, Compliance, HIPAA, Computer Responsibility, Accreditation Standards, Attendance, Staff Qualifications and Quality Management Accountabilities.

Our Commitment

Blue Cross Blue Shield of Arizona does not discriminate in hiring or employment on the basis of race, ethnicity, religion, national origin, sexual orientation, gender, disability, age, covered veteran status or any other protected group.

Thank You

Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see

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17 reviews