Registered Nurse Coder - DRG Reviewer (Remote) ID-6739

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.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:



Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per month.

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.
  • Maintain all standards in consideration of State, Federal, BCBSAZ and other accreditation requirements.
  • Maintain productivity and accuracy goals based on regulatory requirements, accreditation standards, and service level agreements.
  • Demonstrate ability to acquire specialized knowledge to complete all types of projects for all lines of business using appropriate benefit plan booklet, administrative guidelines and policies, medical criteria guidelines, claims research, provider contracts and fee schedules, communication records research and precertification research.
  • Adheres to BCBSAZ brand promise of being a "Trusted Advisor" by walking in the customers shoes including processing work using the principles of easy, effective, emotional
  • Maintaining Return on Investment (ROI) tracking
  • Other duties as assigned (HEDIS, Quality improvement, outreach)



level II

  • Ability to demonstrate specialized knowledge to do in-depth research and provide accurate written documentation
  • Prepare and deliver reports and documentation for committee presentation and ad hoc reports as needed.
  • Maintaining Return on Investment (ROI) tracking



level III

  • Prepare and deliver reports and documentation for committee presentation and ad hoc reports as needed.
  • Assist in developing new policies and procedures, desk levels, and job aids as needed.
  • Assist in training new staff and provide ongoing training for existing staff as needed.
  • Identify and recommend process improvements.
  • Maintain Return on Investment (ROI) tracking and prepare ROI summary as directed by management
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Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

This is what this question poses: When do you focus and start working seriously? What are the hours you work optimally? Are you a night owl? A morning bird? Remote teams can be made up of people working on different shifts and around the world, so you won't necessarily be stuck in the 9-5 schedule if it's not for you...

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This is a great question because it shows your comfort level with technology, which is very important for a remote worker because you will be working with technology over time...

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