PURPOSE OF THE JOB

Responsible for supporting the UM/Care Management Department by providing professional oversight with an emphasis on regulatory requirements and those processes related to State, Federal, BCBSAZ, Accreditation and Medicare. This position will also lead and coordinate or participate in the processes of initial delegation and ongoing oversight of delegated entities. The position will coordinate or participate in the Delegation Committee to assure multi-department compliance and coordination. Additionally, this position will assist in various aspects of accreditation, delegation, and CMS activities.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

5 years of above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, Medical Appeals and Grievance (MAG), Quality Management and/or Accreditation and Medicare requirements.
3 years of experience in clinical and health insurance or other healthcare related field
2 years of Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, Medical Appeals and Grievance (MAG), Quality Management and/or Accreditation and Medicare requirements

Required Education

Associate degree in Nursing or Post High School Nursing Diploma

Required Licenses

Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse

Required Certifications

PREFERRED QUALIFICATIONS

Preferred Work Experience

5 years of above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, Medical Appeals and Grievance (MAG), Quality Management and/or Accreditation and Medicare requirements.
3 years of experience in clinical field of practice, health insurance, or other health care related field
2 years of experience working on healthcare-related systems
2 years of experience in delegation, accreditation, or regulatory environment
1 year of experience leading improvement projects
1 year of experience in data analysis
1 year of experience in accreditation or Medicare Quality Regulations

Preferred Education

Bachelor's Degree in Nursing
Master’s in Nursing, Public Health or other related field

Preferred Licenses

Preferred Certifications

Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHQ), Certified Professional in Healthcare Quality, or Certified Managed Care Nursing

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

Develop and document health improvement/management programs for members in compliance with applicable state, federal, accreditation and Medicare regulations.
Support business processes and data flows and how they affect health management/BCBS processes, systems and other operational areas
Participate in and/or lead process improvement, quality for accreditation or Medicare improvement projects
Analyze and/or oversight of program data collection and reports to evaluate current programs.
Research and analyze procedural problems and provide recommendations for improvements and changes
Consult and coordinate with various internal departments, external plans, providers, vendors, businesses and government agencies to obtain information to meet departmental projects and goals.
Create and maintain the following as applicable:
- Policies for the UM/Care Management Departments
- Documentation of processes to maintain URAC accreditation and Medicare regulations
- Responsible for the running or participating in the Delegation Committee. Activities may include scheduling, documentation and retention of all materials per the BCBSAZ guidelines
- Provide and/or monitor and audit all evidence provided by the vendors to ensure complete and gaps are closed.
Create and/or update correspondence as required per the position.
Development and delivery of training materials to stakeholders in Accreditation and Regulatory processes.
Monitor delegated entities for quality and contract requirements and maintain reporting for evaluation and departmental reporting.
Document and record facts in regard to inquiries, correspondences and projects by updating files and systems.
Demonstrate and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals.
Maintain all standards in consideration of State, Federal, FEP, Medicare, BCBSAZ and other applicable regulatory/accrediting agency requirements as they apply to department functions.

The position requires a full-time work schedule. Full-time is 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.

COMPETENCIES

REQUIRED COMPETENCIES

Required Job Skills

Intermediate knowledge of information systems including Microsoft office suites plus public and proprietary software applications
Intermediate knowledge of CPT-4, HCPCS, ICD-9 and ICD-10 coding

Required Professional Competencies

Health care payer business knowledge including supporting processes, operational data and functions
Maintain confidentiality and privacy
Analytical knowledge to research and make decisions based on available information to complete activities
Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards
Knowledge of managed care delivery models across the continuum of care
Compose a variety of business correspondence
Interpret and translate policies, procedures, programs and guidelines
Establish and maintain working relationships in a collaborative team environment
Organizational skills with the ability to prioritize tasks and work with multiple priorities
Independent and sound judgment with good problem-solving skills

Required Leadership Experience and Competencies

Ability to use available information to focus project’s scope and identify priorities
Represent BCBSAZ in the community
Demonstrate effective presentation skills

PREFERRED COMPETENCIES

Preferred Job Skills

Advanced knowledge of information systems including Microsoft office suite (excel, visio, word,etc.) plus public and proprietary software applications
Advanced knowledge of CPT-4, HCPCS, ICD-9 and ICD-10 coding
Knowledge of URAC standards, survey/or Medicare requirements.
Knowledge of systems development, database systems, and data management.

Preferred Professional Competencies

Working knowledge of InterQual® criteria/Milliman Coverage Guidelines
Knowledge of health management systems
Advanced systems research and analysis expertise.
Ability to write test and execute test plans
Knowledge of business requirements development and user acceptance testing
Comprehensive knowledge of the following: credentialing, URAC, NCQA, HEDIS,CAHPS, medical policies issues and utilzation management.

Preferred Leadership Experience and Competencies

Project Management

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.

Blue Cross and Blue Shield of Nebraska

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