Registered Nurse Coder – DRG Reviewer (Remote) | Blue Cross Blue Shield careers Arizona id-14562

January 11, 2025

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.

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.

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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

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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...

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

When you're working on a remote team, there's no way to chat in the hallway between meetings or catch up on the latest project during an office carpool. Therefore, virtual communication will be absolutely essential to get your work done...

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

Many people want to work remotely because of the flexibility it allows. You can work anywhere and at any time of the day...

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

With this question, companies are looking to see what equipment they may need to provide you with and to verify how aware you are of what remote working could mean for you physically and logistically...

5. HOW DO YOU PROCESS INFORMATION?

Several years ago, I was working in a team to plan a big event. My supervisor made us all work as a team before the big day. One of our activities has been to find out how each of us processes information...

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

Or you may receive even more specific questions, such as: What's on your calendar? Do you plan blocks of time to do certain types of work? Do you have an open calendar that everyone can see?...

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

Just like your schedule, how you track files and other information is very important. After all, everything is digital!...

8. HOW TO PRIORITIZE WORK?

The day I watched Marie Forleo's film separating the important from the urgent, my life changed. Not all remote jobs start fast, but most of them are...

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

Just as communication is essential when working remotely, so is organization. Because you won't have those opportunities in the elevator or a casual conversation in the lunchroom, you should take advantage of the little time you have in a video or phone conference...

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

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...

DISCLAIMER

Other Jobs You May Be Interested In

Common Interview Questions And Answers

1. HOW DO YOU PLAN YOUR DAY?

2. HOW DO YOU USE THE DIFFERENT COMMUNICATION TOOLS IN DIFFERENT SITUATIONS?

3. WHAT IS "WORKING REMOTE" REALLY FOR YOU?

4. WHAT DO YOU NEED IN YOUR PHYSICAL WORKSPACE TO SUCCEED IN YOUR WORK?

5. HOW DO YOU PROCESS INFORMATION?

6. HOW DO YOU MANAGE THE CALENDAR AND THE PROGRAM? WHICH APPLICATIONS / SYSTEM DO YOU USE?

7. HOW DO YOU ORGANIZE FILES, LINKS, AND TABS ON YOUR COMPUTER?

8. HOW TO PRIORITIZE WORK?

9. HOW DO YOU PREPARE FOR A MEETING AND PREPARE A MEETING? WHAT DO YOU SEE HAPPENING DURING THE MEETING?

10. HOW DO YOU USE TECHNOLOGY ON A DAILY BASIS, IN YOUR WORK AND FOR YOUR PLEASURE?

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