Insurance Utilization Reviewer Jobs in Phoenix, AZ

• Direct, lead and provide professional oversight for medical management activities related to utilization management, case management, disease management, and quality management activities. Support collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals and to ensure that medical policies, procedures and the activities/actions of the division on behalf of the corporation are consistent with the standards of good medical practice in the community.

REQUIRED QUALIFICATIONS

• 3 years of experience in a clinical setting
• 1 year of experience in physician leadership role, including quality review, utilization review and other managed care functions

• Medical Degree

• Active, current, and unrestricted license to practice medicine in the State of Arizona (a state in the United States)

• Board Certification

PREFERRED QUALIFICATIONS

• 3 years of experience in a primary care field

• N/A

• N/A

• N/A

• Provide direction, support and medical expertise and oversight to areas within the Health Services Division such including utilization management, quality management, case management, medical claims review, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, precertification, medical claims reconsideration and retrospective review.
• Provide consultative services throughout the corporation, including for the Marketing, Sales, Legal, Actuarial, Network Management, Internal Audit, Finance, and Claims Divisions.
• Communicate with customers regarding their difficult and costly cases, including recommendations and showing the impact of BCBSAZ interventions.
• Seek to improve department/division efficiency through effective use of information system tools and processes to reduce healthcare costs, increase quality of care and service, and reduce administrative expense.
• Review, and implement medical policies and other medical decision making policies or procedures
• Represent BCBSAZ at professional organizations and acts as liaison with individual health care professionals and supports collaborative relationships with physicians and hospitals.
• Provide professional oversight for the various clinical peer committees including, but not limited to, the Clinical Quality Improvement Committee, Credentialing Committee, Medical Directors Committee, and Medical Management Committee.
• Participate in the appeals and grievance processes to assure timely and accurate responses to members and providers
• Individuals who conduct a clinical peer review must possess a license or certification in a health profession that is:
  • Of the type and scope that permits them to apply their clinical judgement in consideration of an individual member's clinical needs to render a utilization review determination
  • For either a Doctor of Medicine or Doctor of Osteopathic Medicine; or is the same license or certification as the ordering practitioner
  • Knowledgeable of the issue under review, or of the current, evidence-based clinical guidelines and novel treatments for the medical or behavioral health condition, disease, treatment, or procedure under review
  • Qualified to render a clinical opinion or determination about the medical or behavioral health condition, procedures, and treatment under review
• Conduct, as appropriate, Appeal Peer Review cases in accordance with the required qualifications.
• Provide written information to members and providers through letters and articles in member and provider newsletters and other publications.
• Work to ensure productive relationships with all customers, employers, members, and providers to ensure members receive the appropriate health care in the most appropriate setting with the best value in health care.
• Provide leadership to staff and other professionals through clinical excellence, professional behavior, and innovative thinking.

• Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.
• Identify opportunities to achieve administrative efficiencies while maintaining service.
• Maintain effective working relationships to ensure teamwork in achieving corporate goals.
• Contribute to departmental and cross-functional teams to achieve BCBSAZ goals and ensure future success.
• Coordinate activities between multiple divisions to achieve desired results.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
• Perform all other duties as assigned.