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The nurse ensures the accuracy and timeliness of prior authorization requests by utilizing evidence-based standards for Medicaid and Medicare members. They also manage the Notice of Action process and coordinate care across departments to ensure quality outcomes.
Requirements summary
Candidates must have an active, unrestricted nursing license in Arizona and at least 3 years of clinical experience. Additionally, 1 year of experience in Medicaid/Medicare, prior authorization, and NCQA standards is required.
associate degreeMedicaidCare coordinationRegulatory complianceQuality improvementChart reviewUtilization reviewMicrosoft officeClinical nursingAnalytical problem solvingPrior authorizationMedicare advantageNCQA standardsNotice of actionElectronic medical management systems
Job description
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 remote work opportunity requires residency, and work to be performed, within the State of Arizona.
PURPOSE OF THE JOB Ensures accuracy and timeliness in the completion of prior authorization (PA) requests to meet contractual requirements and ensures all reviews utilize nationally recognized and evidence-based standards for the Medicaid Segment which includes Medicaid and Medicare Advantage / Dual Eligible Special Needs Plan (D-SNP), and Affordable Care Act (ACA) members.
Ensures the completion, accuracy, and timeliness in the Notice of Action (NOA) process.
QUALIFICATIONS REQUIRED QUALIFICATIONS Required Work Experience 3 years of clinical experience 1 year of Medicaid/Medicare experience 1 year prior authorization and member and provider notification (NOA) experience 1 year experience with National Committee for Quality Assurance (NCQA) standards Required Education Associate degree in Nursing Required Licenses Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN or LPN.
Benefits
Health insurance
Required Certifications N/A PREFERRED QUALIFICATIONS Preferred Work Experience 3+ years of experience in managed care 3+years of experience in prior authorization/utilization review Preferred Education Bachelor of Science in Nursing Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES ALL LEVELS Ensures the accuracy and timeliness of prior authorization requests to meet contractual requirements.
Coordinates and manages the established preauthorization review process for pre-service requests.
Ensures the use of nationally recognized and evidence-based standards in the completion of all pre-service reviews.
Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request(s) to the medical director for determination when criteria not met.
Clearly define and document review rationale to support approval, Medical Director Review and/or Notice of Action document.
Initiates interdepartmental coordination to ensure quality and timely care for members.
Participates in Quality Improvement Projects as directed.
Participate in department audits and other regulatory activities.
Engage cross-functionally and participate in special projects as needed.
Performs Notice of Action (NOA) process.
Participate in annual policy and procedure review and revision.
Perform all other duties as assigned.
The position requires a full-time work schedule,40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
COMPETENCIES REQUIRED COMPETENCIES Required Job Skills Computer skills to include Microsoft Office applications, Word, Excel, and Outlook Ability to use electronic medical management systems Analytical problem solving skills Required Professional Competencies N/A Required Leadership Experience and Competencies N/A PREFERRED COMPETENCIES Preferred Job Skills N/A Preferred Professional Competencies N/A Preferred Leadership Experience and Competencies N/A Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona.
For more information on our company, see azblue.com.
If interested in this position, please apply.
Imagine doing life-changing work and helping more than one million Arizonans live healthier and longer lives.
That’s the kind of satisfaction you’ll find when you work here.
Our exceptional teams in Phoenix, Tucson, Chandler, and Flagstaff have been transforming healthcare for more than 80 years.
Explore what's possible with a career at Blue Cross® BlueShield® of Arizona
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