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Appeal and Grievance Coordination Research Reviewer - Hybrid ID-17080

About the position

The Appeal and Grievance Coordination Research Reviewer position at Blue Cross Blue Shield of Arizona is a full-time role that requires performing research and processing of appeals, grievances, corrected claims, medical records, and related correspondence. This work is conducted in accordance with BCBSAZ, State, Federal, and other accreditation requirements. The position is hybrid, meaning that it requires residency and work to be performed within the State of Arizona. The primary purpose of this job is to ensure that all requests for medical grievances and appeals are analyzed and resolved efficiently, adhering to the timeliness standards set by various regulatory bodies. In this role, the reviewer will maintain advanced knowledge of multiple systems, including vendor medical management and claims systems. They will conduct research to resolve requests from members, providers, and other Blue Plans, ensuring compliance with State, Federal, and URAC standards. The reviewer will also be responsible for reviewing medical records to determine if they meet the necessary criteria for supporting information. Additionally, they will communicate decisions through appropriate system updates and analyze trends in appeals and grievances to report findings to management. The position requires a commitment to excellent customer service and the ability to work independently with limited supervision. The reviewer will also assist in utilization studies and analysis, monitor proxy boxes for pharmacy appeals, and ensure compliance with HIPAA regulations. The role includes various levels of responsibility, with opportunities for advancement based on experience and performance. Overall, this position plays a crucial role in the operational success of the appeals and grievances process within the organization.

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Responsibilities

  • Perform analysis and research of requests received for medical grievances and appeals for final resolution or referral to the Clinical Medical Appeals and Grievance (MAG) Staff.
  • Maintain 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.
  • 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.
  • 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.
  • Use pharmacy system to research and prepare level 2 and external pharmacy cases.
  • Monitor proxy box for pharmacy appeals and grievances.
  • Demonstrate 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.
  • Process records/document requests related to appeals and grievances.
  • Research and reopen claims appeals for diagnosis mismatch.
  • Assist with research and preparation of appeals files for accreditation site visits.

Requirements

  • 1 year of experience in claims processing, medical/pharmacy precertification, appeals and grievances coordination or other applicable related work experience.
  • High-School Diploma or higher.
  • Intermediate PC proficiency.
  • Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones.
  • Intermediate skill in word processing, spreadsheet and database software.
  • Intermediate written communication and letter writing skills.

Nice-to-haves

  • 2 years of experience in a lead or senior claims role.
  • 3 years of experience in claims processing and correspondence with multiple claims systems.
  • 2 years of experience in the medical or healthcare related field.
  • 3 years as a pharmacy technician or precertification technician.
  • Bachelor's degree in business/healthcare or related field.
  • Certified Coder.

Benefits

  • Health insurance coverage
  • Flexible scheduling options
  • Paid holidays
  • Professional development opportunities
  • Employee discount programs
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