Medical Appeals and Grievance (MAG) Registered Nurse Specialist II - 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. 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: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building 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 week. This position is remote within Arizona or in an approved out-of-state location. Applicants must reside in—and perform work from—the state of Arizona or an approved out-of-state location. Purpose of the job Responsible for utilizing clinical acumen and managed care expertise related to researching, resolving and responding to requests for member and provider appeals, grievances, reconsiderations and corrected claims for all lines of business with emphasis on privacy, accuracy, meeting all regulatory and compliance timelines. Qualifications REQUIRED QUALIFICATIONS Required Work Experience Level 1 1 year Experience in clinical and health insurance or other healthcare related field Level 2 3 years' Experience in clinical and health insurance or other healthcare related field 1 year' Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) Level 3 5 years' Experience in clinical and health insurance or other healthcare related field 2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) Level 4 8 years' Experience in clinical and health insurance or other healthcare related field 3 years' Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) 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) or a compact state as a Registered Nurse (RN) Required Certifications N/A   PREFERRED QUALIFICATIONS Preferred Work Experience Level 1 3 years' Experience in clinical and health insurance or other healthcare related field. Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies. Advanced ability to interpret contract language and benefits Level 2 5 years' Experience in clinical and health insurance or other healthcare related field. Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies. Advanced ability to interpret contract language and benefits 2 years' Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) Level 3 7 years' Experience in clinical and health insurance or other healthcare related field. Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies. Advanced ability to interpret contract language and benefits 5 years' Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) Level 4 9 years' Experience in clinical and health insurance or other healthcare related field. Working knowledge of eviCore, MCG, McKesson InterQual® criteria and Medical Coverage Guidelines/Medical Policies. Advanced ability to interpret contract language and benefits 5 years' Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management and/or Medical Appeals and Grievance (MAG) Preferred Education Bachelor's Degree in Nursing or related field of study (Applies to All Levels) Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL job functions AND RESPONSIBILITIES Level I Perform in-depth analysis, clinical review and resolution of provider appeals/inquiries, corrected claims and subscriber reconsiderations, member appeals, corrected claims and provider grievances for all lines of business Identify, research, process, resolve and respond to customer inquiries primarily through written / verbal communication. Respond to a diverse and high volume of health insurance appeal related correspondence on a daily basis. Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropri