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 Under the direction of the Prior Authorization Management (PA), ensures prospective review/prior authorization requests are completed in a timely fashion to meet contractual requirements and ensures all reviews are conducted using nationally recognized and evidence-based standards. QUALIFICATIONS REQUIRED QUALIFICATIONS Required Work Experience 2 years of clinical experience 1 year of Medicaid/Medicare experience 1 year of experience managing multiple projects 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. Required Certifications N/A PREFERRED QUALIFICATIONS Preferred Work Experience 1 year of experience in managed care 1 year of experience in prior authorization/utilization review Preferred Education Bachelor's Degree in Nursing Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES ALL LEVELS Ensures prior authorization requests are completed accurately, thoroughly, and in a timely fashion to meet contractual requirements. Coordinates and follows the established preauthorization review process for pre-service requests. Ensures all reviews are conducted using nationally recognized and evidence-based standards. Utilize clinical skills, chart review, physician communication and appropriate criteria for approval of pre-service requests; escalate pre-service request to the Medical Director for determination when criteria is 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. Assists the management team and others in preparation for audits and other regulatory activities. Assists with other departments and special projects as needed RN Performs audits of case files and staff documentation as directed Assists with orientation and training of all staff Assists with annual criteria review Assists with implementation of process changes as needed Each progressive level includes the ability to perform the essential functions of any lower levels. Perform all other duties as assigned. The position has an onsite expectation of 0 days per week and 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 COMPETENCIES REQUIRED COMPETENCIES Required Job Skills Computer skills 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