Director Clinical Quality, and Accreditation-Registered Nurse w 5 yrs Quality Accreditation in Medicare/Medicaid
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,800 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering 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.
- Develops, implements and oversees an organization wide Accreditation Plan resulting in successful attainment of Accreditation. Develops and directs accreditation preparation activities and accrediting body reviews.
- Develops and executes an organization wide accreditation related quality improvement program resulting in measurable outcomes, oversees and directs quality management activities related to regulatory compliance requirements including those required for accreditation under NCQA or URAC, and related requirements as an issuer of Qualified Health Plans under the Affordable Care Act.
- Oversees the annual ACA HEDIS/QRS cycle, identifying opportunities for improvement in scores and better clinical outcomes.
- Leads the Medicare Quality Improvement Program, oversees and executes the Medicare Quality Workplan, Quality Program Description, Annual Evaluation and Chronic Care Improvement Program.
- Responsible for monitoring key performance measurement activities organization wide and provides direction and recommendations of quality improvement programs.
- Oversees Quality of Care Concerns for Medicare and the commercial lines of business.
- Ensures compliance of all QI programs with CMS, federal and state regulations.
- Establish strategic plans to ensure quality programs are consistent with overall BCBSAZ quality strategies.
- Leads the Appeals and Grievances for FEP and Commercial lines of business.
Required Work Experience
- 5 years of experience in the application of managed care practices
- 5 years of quality and management experience
- 5 years of accreditation experience
- 5 years of Medicare or Medicaid experience
- Bachelor’s degree in a Health Services related field
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a registered nurse (RN).
Preferred Work Experience
- 3 years’ experience in Quality Management , continuous quality improvement and outcomes reporting
- 3 years of experience in developing short and long range strategic plans, forecasting, and budgeting
- 5 years of experience in providing leadership to an established, sophisticated medical/health management division of a health insurance organization
- Post-graduate education in Health Care Administration, Public Health and/or M.B.A.
- Certified Specialist in Healthcare Accreditation (CSHA)
- Certified Professional in Healthcare Quality (CPHQ)
ESSENTIAL job functions AND RESPONSIBILITIES
- Develop and implement an Accreditation Program to include organization wide training and preparation for accreditation surveys, and ongoing readiness activities
- Coordinate and oversee regulatory activities to ensure integration and cohesion throughout accredited divisions
- Act as resource to staff and other departments in the area of accreditation and quality improvement
- Coordinate and submit applications, attestations, and required accreditation documents to the accrediting body and CMS
- Coordinate and supervise accreditation reviews and function as the liaison between the organization and the accrediting body
- Develop and train staff on the use of processes and tools to assess compliance with accreditation standards
- Develop and implement an ongoing accreditation readiness assessment program
- Ensure a comprehensive delegation oversight program is in place. Evaluates and modifies oversight program as needed to ensure ongoing business needs and requirements met.
- Participate on internal, external and Association workgroups and teams as needed
- Complete quality and/or accreditation related templates and forms in HIOS for the annual QHP application
Quality Monitoring and Improvement
- Ensure compliance with CMS regulations related to Medicare for all Quality Programs including CCIP
- Oversight of the CMS regulations for the Quality Improvement Program and Quality of Care Concerns.
- Collaborate with the Government Stars leadership to ensure all quality programs are aligned.
- Ensure compliance with the Affordable Care Act Quality Regulations related to Accreditation, Quality Improvement Strategy and Qualified Health Plan Application
- Coordinate accreditation related quality improvement initiatives. Provide expertise and guidance to others contributing to the process of standards and guideline development.
- Assist leadership monitoring and analysis of accreditation outcomes to promote meeting goals, objectives, accreditation, and regulatory requirements, and accreditation related quality improvement activities are effective.
- Prepare and deliver Executive Summary reports.
- Provide direction and oversight to continuous quality improvement initiatives impacting positive outcomes and improved HEDIS and QRS clinical scores and ratings.
- Coordinate and assist in development of enhancements to existing systems or creations of new systems to improve efficiencies to processing.
- Develop and implement policies and procedures to meet state, regulatory and accreditation requirements.
- Provide oversight for the annual cycle of quality outcomes measurements including but not limited to Healthcare Effectiveness Data and Information Sets (HEDIS®), Quality Rating System, URAC measures.
- Maintain Business Continuity Plan for the Quality Department annually.
- Plan, organize and direct staff to optimize the day to day operations of the quality and accreditation department.
- Serve as the subject matter expert to the internal organization for accreditation and clinical quality
Appeals and Grievances
- Provide leadership and ensure compliance with all external regulatory agencies related to the application of Commercial and FEP Appeals and Grievances processing.
- Oversee operational activities related to mandated and voluntary levels of precertification / claim appeals and grievances.
- Provide leadership, administrative and management support, strategic planning and overall direction of the intake, resolution and follow through for appeals and grievances.
- Oversee and negotiate vendor contracts for peer specialty reviews. Oversee the ongoing delegation of existing independent review organization (IRO) contracts
- Assume a leadership role in the development of any direct reports and acquisition of new talent by providing challenges and opportunities for awareness and growth
- Monitor quality measures, develop and maintain effective workflows, and recommend system efficiencies.
- Maintain effective working relationships to ensure teamwork in achieving corporate goals.
- Foster good communication with staff by setting clear directives, objectives and providing exchange of ideas
- Provide leadership and recommend change management principles to ensure they maximize benefit and alleviate unnecessary disruption.
- Collaborate with Data Science and Analytics to analyze utilization and identify opportunities to offer additional health management services to various customer segments, as well as, trend analysis and development of services for program advancement.
- Manage use of corporate funds including budgeting, financial management, and reporting. Monitor and report on quarterly budget variances. Identify opportunities to achieve administrative efficiencies while maintaining service.
- Establish department goals in accordance with overall BCBSAZ objectives and divisional strategic planning
- Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZ’s future success.
- Ensure the existence of documented department policies and procedures.
- Coordinate activities between multiple divisions to achieve desired results.
- Volunteer within the community to help BCBSAZ give back to community charitable efforts.
- 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.
Required Job Skills
- Strong organizational skills
- Strong written and verbal communications.
- Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones.
- Strong skill in word processing, spreadsheet and database software.
- Strong PC proficiency.
Required Professional Competencies
- Excellent management skills as they relate to clerical and professional staff
- Comprehensive knowledge of Medicare Advantage program regulations including Quality Program, Quality of Care Complaints, and the CCIP.
- Comprehensive knowledge of Accreditation processes and compliance.
- Interpersonal skills that allow for harmonious relationships with providers, members and coworkers
- Ability to successfully function in an environment characterized by risk taking, rapidly changing market conditions, strong competition and restructuring.
- Proven knowledge of medical care delivery systems, quality management, benefit interpretation, provider relationships, and member services.
- Strong understanding of the costs/quality challenges of today’s health care environment.
- Strong understanding of quality metrics and measurement methods.
- Ability to identify key strategic performance measures for success
Required Leadership Experience and Competencies
- The capacity, maturity, stature, and communication skills to assume a leadership role in a progressive, growing, and changing organization.
- Ability to work with business unit managers in a partnership setting.
- Ability to work with executive leadership in a professional and collaborative role.
Preferred Job Skills
Preferred Professional Competencies
Preferred Leadership Experience and Competencies
BCBSAZ 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