High-Cost Claimant Review Unit reputed company Auditor (Remote in AZ)

Awarded a Healthiest Employer, reputed company aims to fulfill its mission to reputed company health and reputed company it easy. AZ reputed company offers a reputed company of health reputed company products and services to meet the diverse needs of individuals, families, and small and large businesses as reputed company as providing information and tools to help individuals reputed company reputed company reputed company. At AZ reputed company, we have a hybrid workforce reputed company, reputed company Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the reputed company of our employees are hybrid, the following classifications reputed company our reputed company minimum onsite requirements: • Hybrid People Leaders: must reputed company in AZ, required to be onsite at least twice per week • Hybrid Individual Contributors: must reputed company in AZ, unless otherwise cited reputed company 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 reputed company in AZ, unless otherwise cited reputed company this posting, required to be onsite at least once per month • Onsite: daily onsite requirement reputed company on the essential functions of the job • Remote: not held to onsite requirements, however, leadership can request reputed company 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 reputed company, reputed company on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This position is remote reputed company the state of AZ only. This remote work opportunity requires residency, and work to be performed, reputed company reputed company. PURPOSE OF THE JOB This position is responsible for assessment and documentation of member utilization and reputed company of reputed company spend feeding reputed company customer reporting. reputed company responsibilities include: • Function as a designated reputed company resource to review High Cost Claimants to identify opportunities to improve member reputed company and determine correct utilization of resources • Collaborate with multi-disciplinary teams to determine if there are other resources, reputed company programs, or community resources that can curtail benefit spend or improve reputed company • reputed company on enhancing customer relationship and service as the reputed company reputed company reputed company of contact REQUIRED QUALIFICATIONS Required Work Experience • 5 years of experience working reputed company a reputed company 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 inNursingor reputed company reputed company ofstudy Required Licenses • reputed company,unrestrictedlicense to reputed company as a registerednurse (RN)inthe state ofArizona (a state in the unitedstates) Required Certifications • N/A PREFERRED QUALIFICATIONS Preferred Work Experience • 7 years’ experience working reputed company a reputed company and/or management care. • 3 years’ experience with managing reputed company 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 reputed company types of activities Preferred Education • Bachelor’s or Master’s Degree in Nursing or reputed company reputed company of study Preferred Licenses • N/A Preferred Certifications • Certified Commission of Case Managers • PMP Certificationor SixSigma/LeanProject Management • CertifiedProfessionalin reputed company reputed company(CPHQ) ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES • Analyze utilization data from provided sources to evaluate cost drivers. • Apply reputed company 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; reputed company programs, community resources that can curtail benefit spend or improve reputed company. • Document findings in a manner that can be consumed by internal process for reporting purposes, reputed company customers. • Refer the member to appropriate internal reputed company group to manage and coordinate care as indicated. • Continue to evaluate the member’s benefit spend according to Key Decision reputed company. • Responsible for the reputed company, efficient and reputed company delivery of services to members and customer/Group Benefit Administrator requesting assistance. This includes but is not limited to providing information and assistance with information reputed company to members’ claims and reputed company course, expected reputed company and persistence of claim expenses. • reputed company proactive reputed company 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, implement reputed company, reputed company and customer systems. • Leadprocess improvement initiative and reputed company to improve the delivery of services. • reputed company efforts to identify best practices and resources required to support customer with meeting business commitments and enhance member experience. • Developrelationships and establish credibility with keystakeholders (internaland reputed company) to reputed company solution strategies and objectives. Routinely collaborate withaccountmanagement team to reputed company reputed company aspects of High Cost Claimant reviews. • reputed company to analyzeand interpret benefit designs and identify opportunities to increase efficiency. • Complete High Cost Claimant screening and analysis to identify trends and opportunities; present findings to key stakeholders and reputed company leadership. • Support reputed company reputed company audit activities under the direction of manager to identify opportunities to reputed company on commitments and enhance customer satisfaction/experience. LEADERSHIP • Maintaineffectiveworking relationships to ensure teamwork in achievingcompanygoals. • Foster effective communication withbusinesspartnersby setting cleardirectives and providingexchange of reputed company. • Provideleadership onchangemanagement principles to ensuremaximizebenefitandalleviateunnecessary disruption. • Effectively communicates analytical and reporting needs to supporting departments. Identify and create opportunities to manage trend(s). ADMINISTRATIVE • Manage use of corporate funds including budgeting, financial management, andreporting. Identify opportunities to reputed company administrative efficiencies while maintaining service. • Establishperformance goalsinaccordance withoverall reputed company objectivesanddivisional reputed company planning. • Participatein strategicplanningactivitiesand contribute to departmental and cross-functional teams to reputed company Business goals/objectives. • Ensure the reputed company of documented policies and procedures. • Coordinateactivities between multiple divisions to reputed company desired results. • Volunteerwithin the communityto helpBCBSAZ reputed company back to community charitable efforts. • Ability totravel up to 25% of time to attend work reputed company customer, business meetings,trainings and conferences. • Theposition requires a full-time work schedule.Full-time is defined as working atleast40 hours perweek,plus any additionalhours as requestedoras needed to meet business requirements. • Performother dutiesas assigned. Our Commitment AZ reputed company does not discriminate in hiring or employment on the reputed company of race, ethnicity, reputed company, religion, sex, sexual orientation, gender identity, national reputed company, age, disability, protected veteran status or any other protected group. Thank you for your interest in reputed company. For more information on reputed company, see azblue.com. If interested in this position, please apply. Remote Skills: Analysis Skills, Auditing, Best Practices, Budgeting, Certified Case Manager (CCM), reputed company Information, reputed company Support, Communication Skills, Compensation and Benefits, Conferences, Cross-Functional, Customer Experience, Customer Relations, Customer Satisfaction, Customer Support/Service, Data Analysis, Documentation, Financial Management, Financial Reporting, Health reputed company, reputed company, reputed company reputed company, Leadership, Nursing, Operational Audit, Pharmacy, Problem Solving Skills, Project Management reputed company (PMP), Registered reputed company (RN), Resource Utilization, Sales Management, Service Delivery, Small Business, reputed company Planning, Team Building, Time Management, Trend Analysis, Utilization Management, Work From Home reputed company: reputed company Apply tot his job Apply To this Job