Initial Clinical Reviewer

This is a fully remote position, open to applicants in Arizona.

📋 Description

• Responsible for identifying, researching, processing, resolving, and addressing inquiries from both internal and external customers, with a strong emphasis on excellence, privacy, compliance, and adaptability within the health insurance sector.

• Handle a wide range and high volume of customer calls or correspondence related to health insurance on a daily basis.

• Review medical records and apply medical necessity criteria along with benefit plan requirements to assess the appropriateness of benefit requests.

• Maintain complete and accurate records in accordance with departmental policy.

• Achieve individual and departmental performance goals by meeting quality, quantity, and timeliness standards as outlined in department guidelines and stipulated by State, Federal, and other accrediting entities.

• Provide customers with detailed information regarding the organization’s services, including but not limited to contract benefits, coverage changes, eligibility, claims, BCBSAZ programs, provider networks, and more.

• Exhibit proficiency in applying plan policies and procedures effectively.

• When necessary, assist with team or project functions by collaborating with team members to distribute workload and tasks; monitoring and reporting on team assignments; communicating team-related issues and improvement opportunities to the supervisor or manager; and supporting or mentoring fellow team members.

• Engage in ongoing education and stay informed about current developments in the fields of medicine and managed care while upholding all standards as required by State, Federal, BCBSAZ, and other accreditation bodies.

⛳️ Requirements

• A minimum of 2 years of experience in a clinical practice, health insurance, or a related healthcare field.

• An Associate’s Degree in a general field of study or a Post High School Nursing Diploma or Certification (LPN only) from an accredited program.

• An active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC, LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted nursing license in the State of Arizona or another U.S. state recognized by the Nursing Licensure Compact (NLC) as an RN, OR an active, current, and unrestricted license to practice in Arizona as an LPN.

• Proficient in intermediate PC skills.

• Intermediate skills in operating office equipment, including copiers, fax machines, scanners, and telephones.

🏝️ Benefits

• Health insurance

• Flexible work arrangements