RN Initial Clinical Reviewer

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

📋 Description

• Identify, research, process, and address customer inquiries and correspondence through telephone, written communication, and/or in person.

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

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

• Keep thorough and precise records in accordance with department policies.

• Achieve quality, quantity, and timeliness standards for personal and departmental performance objectives.

• Clarify organizational services, contract benefits, coverage modifications, eligibility criteria, claims processes, BCBSAZ programs, and provider networks to customers.

• Effectively apply plan policies and procedures.

• Collaborate and coordinate with internal departments, external plans, providers, businesses, and governmental agencies to address customer inquiries.

• Work together on team/project functions, allocate workload, monitor and report on tasks, communicate challenges and improvement opportunities, and support or mentor team members.

• Engage in ongoing education and stay updated on current developments in medicine and managed care.

• Ensure compliance with State, Federal, BCBSAZ, and accreditation standards.

• Perform additional duties as assigned.

⛳️ Requirements

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

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

• An active, current, and unrestricted Arizona license (or endorsement) 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 RN license in Arizona or another NLC state; OR an active, current, and unrestricted Arizona LPN license.

• Intermediate proficiency in PC usage.

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

• Uphold confidentiality and privacy standards.

• Strong up-to-date clinical knowledge.

• Excellent interpersonal and active listening abilities.

• Capability to draft business correspondence.

• Ability to interpret and clarify policies, procedures, programs, and guidelines.

• Strong investigative and analytical research skills.

• Proficiency in navigating, collecting, inputting, and maintaining data records across multiple system applications.

• Ability to follow and accept guidance and direction.

• Capability to establish and sustain collaborative working relationships.

• Strong organizational skills and the ability to prioritize multiple tasks effectively.

• Independent judgment and problem-solving capabilities.

🏝️ Benefits

• A hybrid workforce strategy (Workability) that provides flexibility regarding how and where employees work.

• Remote work opportunity with no regular onsite requirements.

• Full-time schedule requiring at least 40 hours per week.

• Opportunities for continuing education and engagement in current developments in medicine and managed care.