Job Description

Awarded the Best Place to Work 2021, 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.


Responsible for promoting ongoing compliance with all NCQA, CMS, and AHCCCS accreditation and regulatory standards and leads clinical operations toward the advancement of a continuous readiness culture. This role is a liaison between clinical operations and all health plan departments, regulatory agencies, and other key internal and external stakeholders.



1. Required Work Experience

· 3 years’ experience in clinical care

· 2 years’ experience in a supervisory role

· Knowledge of NCQA, CMS, and AHCCCS Standards, and experience with implementing processes to ensure

their adherence

2. Required Education

· Bachelor’s Degree in Nursing or master’s degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.)

3. Required Licenses

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

Registered Nurse (RN) or independent license in the behavioral health profession such as LCSW, LPC, LISAC


4. Required Certifications

· N/A


1. Preferred Work Experience

· 5 years’ experience in direct clinical care

· Physical and behavioral health experience

· 3-4 years’ experience in a supervisory role

· 2-3 years of experience working in a managed care organization

· Program development

· Project management

· Knowledge of population health concepts and models

2. Preferred Education

· N/A

3. Preferred Licenses

· N/A

4. Preferred Certifications

· N/A


· Direct all activities required within the clinical operations division to achieve and maintain NCQA accreditation, AHCCCS compliance, and Medicare Model of Care compliance

· Responsible for monitoring and reporting key department and program performance measures and makes recommendations for improvements to operational practices based on the results.

· Collaboratively assess new opportunities and develops actionable tactical plans to meet growth and programmatic objectives

· Lead an analytics team to evaluate the progress of new programs by benchmarking best practices in the clinical departments, identifying measurable outcomes for best practices

· Remain current on new trends and innovations in clinical operations and incorporates accordingly

· Responsible for the review, update and accuracy of documentation, computer files, policies and procedures related to the departmental goals and objectives, and makes recommendations for improvements to operational practices

· Collaborate with other departments as appropriate to improve member and provider experience as well as outcomes

· Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and implement operational changes and process improvement.

· Facilitate opportunities for staff training, continuing education, and development such as identifying needs, developing curriculum, delivering, and coordinating training. This includes clinical decision making and critical thinking related to member’s care and population health.

· Ensure updates related to organizational goals and organizational changes are communicated to staff.

· Perform a formal evaluation of job performance per Blue Cross Blue Shield of Arizona (BCBSAZ) corporate policy to

include review and assessment of the CM program documentation produced by the Care Management staff members.

· Participate in continuing education and current developments in the field of accreditation, medicine, behavioral health, social determinants, and managed care at least annually.

· 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



1. Required Job Skills

· Intermediate PC proficiency

· Intermediate skill in word processing, spreadsheet, and database software

· Excellent communication, collaboration, and delegation skills.

· Proficiency in project management

· Ability to think analytically to resolve issues; solution-focused mindset; creative and innovative

· Ability to manage multiple tasks and prioritize work to adhere to deadlines and identified time frames

· Ability to learn new applications

· Data analytics skills

2. Required Professional Competencies

· Demonstrate knowledge of accreditation, regulatory, and certification requirements

· Advanced and current clinical knowledge

· Assess the impact of existing or new regulatory requirements

· Guide clinical practice and operations with applicable regulations or standards

· Engage key stakeholders in the design, implementation, and monitoring of planned improvements related to compliance with regulatory or accreditation standards

· Work with key leaders to ensure institution-wide policy and procedure changes or revisions are compliant ensuring regulatory readiness

· Provide access to, and education about, regulatory and accreditation standards to stakeholders across the organization

· Develop a structure and process to promote achievement of regulatory, accreditation, and certification programs that advance organizational goals and align essential resources

· Establish routine reporting processes utilizing metrics to monitor impact of participation and outcomes toward accreditation, regulatory and certification achievements

· Manage survey (planned and unannounced) processes including site visit preparation and coordination of site visit logistics and response, and report-out processes to management of major regulatory changes and issues related to mock or real survey results

· Facilitate the development and monitoring of action plans for noncompliant findings including documentation and communication of plans within the organization as appropriate

· Implement a process for monitoring and validating compliance on an ongoing basis to support sustainability

· Position BCBSAZ Health Choice in a continuous readiness state for all survey and site visits

· Develop and oversee ongoing education regarding accreditation, regulatory and certification metrics

· Establish a communication plan for Accreditation, Regulation and Certification programs that includes compliance activities, continuous readiness, and process for planned and unannounced visits

· Work as an internal consultant with medical staff, nursing, support services and other departments to assess regulatory compliance and improve overall patient safety and quality

· Apply process improvement methods (LEAN, PDCA, Six Sigma) to help drive improvements in regulatory and accreditation compliance focusing on patient safety and quality

· Lead a multidisciplinary team that supports accreditation throughout BCBSAZ Health Choice

· Facilitate a process to track and document quality monitoring and improvement processes for contracted services that impact patient care

· Assist Department Leaders with identifying quality metrics in their areas, facilitating quality improvement processes and documenting them within the Annual Quality Report

· Collaborate with Corporate Compliance and Risk Management regarding regulatory requirements and the impact on clinical areas

· Collaborate with Information Technology to maximize the utilization of the medical management system (CareRadius) and technologies to support compliance with clinical metrics for accreditation, regulatory and certification programs

· Apply, teach, and skillfully use techniques for project management, problem solving, facilitation, leadership, conflict management, and team building skills to ensure progress toward achievement of accreditation, regulation, certification, and strategic goals

· Is self-driven, sets annual goals that align with BCBSAZ Health Choice strategic plan, continuous improvement, and compliance with accreditation, regulatory and certification programs

· Analytical knowledge necessary to generate reports based on available data and the ability to make decisions based on reported data

· Capable of investigative and analytical research

· Interpret and translate policies, procedures, programs and guidelines

· Navigate, gather, input and maintain data records in multiple system applications

3. Required Leadership Experience and Competencies

· Make use of employee's skills and abilities to deliver business objectives

· Use available information to focus team's activities and identify priorities

· Ability to develop and build a high performing team culture


1. Preferred Job Skills

· Advanced PC proficiency

2. Preferred Professional Competencies

· Knowledge and understanding of the medical management process

· Process improvement experience (LEAN, PDCA, SixSigma)

3. Preferred Leadership Experience and Competencies

· Demonstrated skills and competence in accreditation and regulatory compliance

· Demonstrated effective presentation skills

· Demonstrated effective leadership skills


Comply with BCBSAZ corporate and departmental policies and procedures, including, but not limited to Code Blue, Compliance, HIPAA, Computer Responsibility, Accreditation Standards, Attendance, Staff Qualifications and Quality Management Accountabilities.

Our Commitment

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  If interested in this position, please apply.

Application Instructions

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