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.

PURPOSE OF THE JOB

This position supports Quality Management department leadership responsible for review of clinical care for appropriate quality; and conducting clinical investigations, reviews, and developing recommendations about quality of care, mortalities and other clinical matters.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

1. Required Work Experience

· 5 year(s) of experience in clinical field of practice, health insurance or other health care related field

2. Required Education

· Master’s degree in counseling, social work, psychology, nursing or related field

3. Required Licenses

· Active, current, and unrestricted behavioral health professional license through the AZ Board of Behavioral Health Examiners or licensed RN

· Valid Arizona Driver License, with an acceptable driving record

4. Required Certifications

· N/A

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

· 5 year(s) of experience in health insurance field/managed care setting

· 2 year(s) experience in Medicaid and/or Medicare

2. Preferred Education

· Master’s degree in counseling, social work, psychology, nursing or related field

3. Preferred Licenses

· Active, current, and unrestricted behavioral health professional license through the AZ Board of Behavioral Health

Examiners or licensed RN

4. Preferred Certifications

· N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

· Assists with managing the quality of care review process and identifies quality of care concerns though screening of reported incidents, accidents and deaths

· Performs review of provider clinical records for quality, utilization and completeness based on state, federal and BCBSAZ policy expectations.

· Conducts clinical investigations, reviews and develops recommendations about quality of care, mortalities and other clinical matters.

· Prepares and presents written reports of review findings for various BCBSAZ committees, BCBSAZ behavioral health homes and state agencies; and providing ongoing technical assistance to provider agencies regarding clinical record

completeness and quality.

· Performs clinical oversight functions such as reviewing of criteria-based clinical activities, processes or programs for adherence to established standards or criteria, and/or information gathering.

· Participates in or collaborates with BCBSAZ committees, projects and work teams as assigned.

· Oversees and manages the reporting of incidents, accidents, and death reports via the AHCCCS QMS Portal, internal quality management referrals, and AHCCCS ad hoc requests

· Assists with managing work unit and employees performing clinical record review to ensure compliance with contract requirements, including oversight, improvement, and monitoring functions

· Assists with managing and overseeing clinical record review of quality of care concerns

· Assists with overseeing and managing routine and hybrid/ad hoc quality management reviews of BCBSAZ- and provider-functions

· Collaborates with internal departments, provider network agencies, internal and external stakeholders and state agencies in all aspects of quality and performance improvement programs

· Some occasional travel may be required.

· Perform all other duties as assigned

· 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

COMPETENCIES

REQUIRED COMPETENCIES

1. Required Job Skills

· Knowledge in the areas of the Arizona behavioral and medical health system including policies, procedures, and contract compliance; clinical and therapeutic best practices; AHCCCS, ADHS, and contract requirements, policies, and procedures; and BCBSAZ clinical and safety policies and procedures.

· Problem resolution, prioritizing, and handling multiple projects.

· Ability to maintain confidentiality, privacy, and security of protected information.

· Strong written and verbal communications. Excellent organizational skills and strong attention to detail.

· Possess proficient computer and technological skills especially Word, Excel, PowerPoint, SharePoint, Teams, Zoom, Internet and telephone.

· Ability to gather, analyze data and prepare informative and accurate business reports.

2. Required Professional Competencies

· Effective, professional, and appropriate communication both verbally and in writing

· Ability to work effectively and efficiently both independently and as part of a team

· Maintain confidentiality and privacy in consideration of State, Federal, BCBSAZ and other accreditation requirements

· Ability to set priorities and appropriately escalate issues to management

· Advanced clinical knowledge, including knowledge of the QOC process

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

· Capable of investigative and analytical research

· Organizational skills with the ability to prioritize tasks and work with multiple priorities

· Independent and sound judgment with good problem solving skills

· Ability to motivate, coordinate and collaborate effectively with team and stakeholders from multiple business areas

3. Required Leadership Experience and Competencies

· Make use of employees’ skills and abilities to deliver business objectives

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

· Resource management skills

· Leadership skills

· The maturity, communication and influencing skills to assume a lead role in a growing, and changing organization.

· Mindset geared toward the creation, execution and continuous improvement

PREFERRED COMPETENCIES

1. Preferred Job Skills

· N/A

2. Preferred Professional Competencies · N/A

3. Preferred Leadership Experience and Competencies

· N/A

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 azblue.com.  If interested in this position, please apply.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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