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Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.AZ Blue offersa 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 position is hybrid within the state of AZ only.This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona.
PURPOSE OF THE JOB
Perform research and processing of appeals, grievances, corrected claims, medical records, and related correspondence in accordance with BCBSAZ, state, federal, and accreditation requirements as applicable.
REQUIRED QUALIFICATIONS
Required Work Experience:
- 1 year of experience in claims processing, medical/pharmacy precertification, appeals and grievances coordination, or related work experience (all levels)
Required Education:
- High School Diploma or higher (all levels)
Required Licenses:
Required Certifications:
PREFERRED QUALIFICATIONS
Preferred Work Experience:
- 2 years of experience in a lead or senior claims role (all levels)
- 3 years of experience in claims processing and correspondence using multiple claims systems (all levels)
- 2 years of experience in a medical or healthcare-related field (all levels)
- 3 years as a pharmacy technician or precertification technician
Preferred Education:
- Bachelor's degree in Business, Healthcare, or related field
Preferred Licenses:
Preferred Certifications:
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES
LEVEL 1 - REVIEWER I
- Analyze and research medical grievances and appeals for final resolution or referral to Clinical Medical Appeals and Grievance staff.
- Maintain advanced knowledge of multiple systems, including medical management and claims systems.
- Conduct research to resolve requests from members, providers, and other Blue Plans in accordance with regulatory and accreditation standards.
- Review medical records to determine if requested supporting documentation is sufficient.
- Complete specific appeals and grievances after clinical training.
- Maintain current knowledge of medical terminology.
- Research and assemble medical records, coverage guidelines, claims, and historical data for clinical review and legal proceedings.
- Perform data corrections and claim adjustments related to appeals.
- Communicate appeal decisions through appropriate system updates.
- Analyze appeals, grievances, and insufficient records for trends and report findings to leadership.
- Assist with utilization studies and analysis.
- Meet department and individual performance goals.
- Perform duties with limited supervision.
- Use pharmacy systems to research and prepare Level 2 and external pharmacy cases.
- Monitor pharmacy appeals and grievance mailboxes.
- Monitor Appeals and Grievance Coordination mailboxes and phones as assigned.
- Demonstrate commitment to excellent customer experience.
- Maintain knowledge of multiple lines of business, including fully insured, self-funded, ACA, and Blue Card products.
- Maintain understanding of medical management and claims processing systems.
- Process records and document requests related to appeals and grievances.
- Coordinate with vendors and special groups regarding appeal communications and documentation.
- Research and reopen claims appeals involving diagnosis mismatches.
- Assist legal teams with research and written communications when directed.
- Complete training and competency attestations.
- Ensure HIPAA compliance and PHI privacy.
- Communicate with the privacy office regarding discrimination grievance requests.
- Assist in preparation of accreditation site visit materials.
- Complete mandatory training and at least three additional training courses.
- Complete Individual Development Plan (IDP) and participate in engagement action plans.
- Maintain current knowledge of state, federal, Blue Card, accreditation, and BCBSAZ appeal and grievance requirements.
- Perform other duties as assigned.
LEVEL 2 - REVIEWER II
Includes all Level 1 responsibilities plus:
- Perform Level 1 and Level 2 activities independently.
- Identify and report trends in grievances, appeals, and medical records.
- Assist Claims Department with customer inquiries.
- Support training and questions for Level 1 Reviewers.
- Perform focused quality audits and report findings.
- Attend Blue Cross Blue Shield Association appeals and grievance meetings as assigned.
- Assist with aging reports.
- Assist with case assignments as assigned.
LEVEL 3 - REVIEWER III
Includes all Level 1 and Level 2 responsibilities plus:
- Perform Level 1 through Level 3 activities independently.
- Initiate claim adjustments or coordinate resolution with appropriate departments.
- Process Blue Card requests.
- Participate in special projects related to claims, recoupments, coding, and medical coverage guidelines.
- Create job aids and maintain department procedures.
- Train and mentor staff.
- Perform focused quality audits and report findings.
- Conduct timely filing reviews for Level 2 requests.
- Perform User Acceptance Testing (UAT) for system upgrades.
ALL LEVELS
- Each progressive level includes the ability to perform the duties of lower levels.
- The position has an onsite expectation of 1 day 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.
- Perform all other duties as assigned.
REQUIRED COMPETENCIES
Job Skills:
- Intermediate PC proficiency
- Intermediate use of office equipment such as copiers, fax machines, scanners, and telephones
- Intermediate proficiency in word processing, spreadsheet, and database software
- Intermediate written communication and letter-writing skills
Professional Competencies:
- Maintain confidentiality and privacy
- Conduct investigative and analytical research
- Build collaborative working relationships
- Practice strong interpersonal and active listening skills
- Interpret and apply policies, procedures, programs, and guidelines
Leadership Competencies:
PREFERRED COMPETENCIES
Job Skills:
- Advanced PC proficiency
- Advanced word processing, spreadsheet, and database skills
- Advanced written communication and letter-writing skills
Professional Competencies:
- Navigate and maintain records in multiple systems
- Understand claims processing logic
- Knowledge of contract benefits and administrative guidelines
Leadership Competencies:
- Experience in a lead or senior claims role
#LI-AB1 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.
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Blue Cross Blue Shield of Arizona
Jul 20, 2026