Manager- Clinical Quality-Registered Nurse-5yrs managed care-Medicare with URAC/NCQA required
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.
Internal use only-grade 31-33
- Manage aspects of quality improvement and management programs and projects that enable our company to measure, monitor, and improve the quality of the care and service provided to our members.
- Oversees Quality of Care Concerns for Medicare and the commercial lines of business.
- Ensures compliance of all Quality of Care Concerns with CMS, URAC, federal and state regulations.
REQUIRED QUALIFICATIONSRequired Work Experience
- 5 years of experience in managed care setting
- 3 years quality improvement experience
- 2 years of experience in a clinical field
- 2 years Medicare or CMS experience
- 2 years of URAC or NCQA experience
- Bachelor’s degree in healthcare administration, public health, nursing, social work or health related field
- Active, unrestricted license to practice as a registered nurse (RN) in the state of Arizona and/or compact state license
PREFERRED QUALIFICATIONSPreferred Work Experience
- 1 year of experience in Quality of Care Concerns
- 5 years of data collection, analysis and reporting
- 5 years of experience in healthcare accreditation
- 2 years of experience in Medicare Advantage
- 5 years of experience leading a team with 8 or more direct reports and/or multiple departments
- Master’s degree in healthcare administration, public health, nursing, social work or other health related field
- Post-graduate certification
- Certified Professional in Healthcare Quality (CPHQ) or other quality-related certification
- Utilization Management and/or Case Management Certification
- Project Management (PMP) Agile
ESSENTIAL job functions AND RESPONSIBILITIES
- Analyzes incidents, sentinel events, and risk outcomes with administrators, physicians, clinical leaders, and staff to identify improvement opportunities utilizing quantitative techniques and knowledge of health care operations and systems thinking. Obtains and uses literature, best practice, and benchmark data
- Manages Quality of Care Concerns department including significant clinical event and root cause analysis, including peer review, process improvement, tracking and reporting of processes, policies and procedures. Identify causes of variation, develop and implement quality improvement processes to facilitate effective clinical practice and error reduction.
- Directs personnel actions including recruiting, new hire actions, interviewing and selection of new staff, salary determinations, training, and personnel evaluations
- Ensure compliance with the Affordable Care Act Quality Regulations related to Accreditation, Quality Improvement Strategy and Qualified Health Plan Application
- Oversight of the CMS regulations for Quality of Care Concerns.
- Provides leadership to assure compliance with federal and state regulatory programs and accreditation requirements, as well as established organizational policies and procedures. Serves as a liaison with stakeholders in other functions to communicate and coordinate on issues of mutual interest
- Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards
- 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 COMPETENCIESRequired Job Skills
- Advanced Proficiency with Microsoft office suite applications
- Strong organizational skills
- Strong written and verbal communications
- Strong PC proficiency
Required Professional Competencies
- Must possess demonstrated flexibility in responding to the needs of multiple constituencies
- Demonstrated ability to lead and facilitate interdisciplinary teams
- Must also possess demonstrated skill in problem analysis, project management, conflict resolution and oral/written presentation
- Requires ability to balance and manage multiple projects
- Excellent management skills as they relate to clerical and professional staff
- 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.
- Ability to identify key strategic performance measures for success
- 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 COMPETENCIESPreferred Job Skills
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