High-Cost Claimant Review Unit Nurse Auditor

Requirements

• Preferred Work Experience
• 7 years' experience working within a healthcare and/or management care.
• 3 years' experience with managing direct customer facing or account management experience
• Experience in working in more than one of Utilization Management, Medical Claim Review and Care Management
• Experience with working with VITAL, Metavance and/or Guiding Care platforms
• Experience in operational analysis, data analysis and problem resolution types of activities
• Preferred Education
• Bachelor's or Master's Degree in Nursing or related field of study
• Preferred Licenses
• N/A
• Preferred Certifications
• Certified Commission of Case Managers
• PMP Certification or Six Sigma/Lean Project Management
• Certified Professional in Healthcare Quality (CPHQ)
• ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
• Analyze utilization data from provided sources to evaluate cost drivers.
• Apply clinical knowledge, incorporating the persistency score to determine if member care needs will be ongoing versus an acute episodic.
• Apply knowledge of customer benefit structure to determine appropriate use of services.
• Collaborate with multi-disciplinary team to determine if there are other resources; BCBSAZ programs, community resources that can curtail benefit spend or improve outcomes.
• Document findings in a manner that can be consumed by internal process for reporting purposes, internal and external customers.
• Refer the member to appropriate internal BCBSAZ group to manage and coordinate care as indicated.
• Continue to evaluate the member's benefit spend according to Key Decision Criteria.
• Provide proactive clinical recommendations, information regarding trends, program and industry changes the customer and member experience.
• Represent customer-internally and coordinate with other departments such as medical and pharmacy account team to address ongoing needs, imp

Benefits

Additional Information

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. PURPOSE OF THE JOB This position is responsible for assessment and documentation of member utilization and prediction of future spend feeding internal and external customer reporting. Primary responsibilities include: Function as a designated clinical resource to review High Cost Claimants to identify opportunities to improve member outcomes and determine correct utilization of resources Collaborate with multi-disciplinary teams to determine if there are other resources, BCBSAZ programs, or community resources that can curtail benefit spend or improve outcomes Focus on enhancing customer relationship and service as the primary clinical point of contact REQUIRED QUALIFICATIONS Required Work Experience 5 years of experience working within a healthcare and/or management care 2 consecutive years' experience as an RN analyst or auditor in Utilization Review, Medical Claim Review and/or Care Management Required Education Associate's Degree in Nursing or related field of study Required Licenses Active, unrestricted license to practice as a registered nurse (RN) in the state of Arizona (a state in the united states) Required Certifications N/A

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