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Director, Integrated Clinical Care - Hybrid

AZ Blue Phoenix, AZ 85021, United States of America

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 position requires work and residency in Arizona.

Purpose of the job

Provide leadership and oversight for clinical operations services, including utilization management, medical claims review, and clinical training and auditing. These services aim to manage medical costs and improve population health. Develop and implement management programs to meet the demographic and epidemiological needs of our members across Commercial, Individual, and government lines of business (FEP and Medicare). Ensure strategic implementation of compliance and regulatory requirements, including accreditation and federal and state mandates.

REQUIRED QUALIFICATIONS

Required Work Experience
  • 7 years of clinical experience
  • 5 years of management experience
  • 5 years of managed care, utilization management review, health services health outcomes, or disease management experience, specifically in developing and implementing clinical programs
  • 5 years of experience in developing short and long range strategic plans, forecasting, and budgeting
Required Education
  • Bachelor’s degree in healthcare, healthcare administration, business administration or related field
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, LCSW, LPC, LISAC LMFT, Psy.D. or Ph.D.
Required Certifications
  • N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience
  • 10 years of management experience
  • 10 years of clinical experience in a primary care field
  • 10 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs
  • 5 years of experience in developing short and long range strategic plans, forecasting, and budgeting
Preferred Education
  • N/A
Preferred Licenses
  • N/A
Preferred Certifications
  • N/A

ESSENTIAL job functions AND RESPONSIBILITIES

  • Provide leadership to medical management operations of utilization management, concurrent review, clinical training & auditing, and medical claims review and ensure they meet the demographic and epidemiological needs of our members.
  • Ensure compliance with all regulatory agencies over Medicare and Commercial business related to the application of Evidence Based Medicine Medical Policy processing, including the CMS Interoperability and Patient Access Final Rule. Ensure all State, Federal, BCBS Association and Accreditation processing requirements are satisfied.
  • Identify data-informed, strategic directions and improvements for health and population management systems and propose options, including budget forecasts, system roadmaps and functionality.
  • Promote plan-wide understanding, communication, and coordination of clinical operation services including cross-functional collaboration across clinical, information technology, compliance, and operational teams to enhance workflows, data exchange, and improve member and provider experience.
  • Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
  • 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 and improved cost of care.
  • Assist with the development and integration of new products as they relate to areas of responsibility including management of requests for proposals and requests for information.
  • Provide leadership, administrative and management support, strategic planning and overall direction of medical management, utilizing the principles of continuous process improvement to impact efficiency, effectiveness and outcomes.
  • Provide leadership and management in the support of workflows to support business growth and evolving strategies. Oversee and coordinate from a business owner perspective, the business requirements, end-to-end testing and user acceptance testing for processes involving areas of responsibility.
  • Ensure appropriate productivity standards are monitored and in line with industry standards; analyze staffing models to support productivity and encourage efficiencies in process.  Forecast staffing-based trends, system changes and healthcare programs.
  • Support development of Medical Policy, technology implementation and publication of the Medical Coverage Guidelines (Medical and Administrative Policy Manual), along with associated clinical criteria, pertinent to medical policy issues.  Oversee interrater reliability throughout the clinicians.

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Overall

  • Demonstrate quality management standards in daily problem solving within respective areas of responsibility leading by example and managing by fact.
  • Ensure new programs are integrated with all functional areas, including delegated entities, and responsive to competitive market demands.
  • Function as an SME for the clinical/medical management programs and presents the programs to clients and other external agencies both in-person and written.
  • Oversee day-to-day departmental administration by coaching and motivating managerial staff and departmental personnel to make maximum use of experience and skills.
  • Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies.
  • Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service.
  • Provide leadership for accreditation activities for areas of responsibility
  • Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZ goals. Support BCBSAZ’s Core Value of maintaining a heritage of service, by volunteering with, serving on, and/or supporting multiple Boards of Directors within the community.
  • This position has in office requirements of two 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 needed to meet business requirements.
  • Maintain effective working relationships to ensure teamwork in achieving corporate goals.
  • Perform all other duties as assigned.

REQUIRED COMPETENCIES

Required Job Skills

  • Strong written and verbal communications.
  • Leadership capabilities with proven success
  • Critical thinking skills
  • Intermediate PC proficiency.
  • Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones.
  • Intermediate skill in word processing, spreadsheet, and database software.

Required Professional Competencies

  • Proven leadership skills over clinical and nonclinical staff; Management skills in an operationally changing environment, with drive for results based on planned objectives.
  • Comprehensive knowledge and background in URAC, medical policy, and utilization management.
  • Strong customer service skills.
  • Ability to influence business leaders and educate providers.
  • Advanced analytical and diagnostic skills dealing with issues that are often novel and not readily defined, lack known precedent or appear contradictory.
  • Interpersonal skills that allow for harmonious relationships with providers, members and coworkers.
  • Recognize strategic opportunities and use data to make timely and sound decisions.
  • Flexibility and willingness to adjust to shifting demands/priorities.
  • Ability and experience to assimilate multiple functions, services, projects and systems while maintaining existing systems and programs.
  • Expert knowledge of medical benefits management, quality initiatives, managed care, contracting, negotiation and relationship building.
  • Conceptual and in-depth knowledge of the healthcare industry, including reform, competition, ancillary provider trends, and reimbursement models.
  • Strong ability to deal with abstract and concrete variables, apply principles of logical or scientific thinking to define problems, collect data, establish facts, and draw valid conclusions.
  • Management skills in an operationally changing environment, with drive for results and success based on planned objectives.
  • Recognize strategic opportunities and use data to make timely and sound decisions.
  • 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 familiarity with the competition, market environment, healthcare economics, medical practices, managed care issues and provider/managed care systems and structures.
  • Ability to identify key strategic performance measures for success

Required Leadership Experience and Competencies

  • High standard of performance while pursuing aggressive goals
  • The capacity, maturity, stature, and communication skills to assume a leadership role in a progressive, growing and changing organization
  • Principled leadership and sound business ethics

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.

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