Registered Nurse-Clinical Auditor
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.
Responsible for developing and delivering clinical curriculum, developmental programs and services to assist with achievement of goals and initiatives. Responsible for conducting clinical audits and reviews to ensure standardization and consistency with nurse reviewer clinical decisions.
Required Work Experience
- 2 years of direct clinical care experience in a healthcare utilization management setting
- 1 year of medicare experience, preferably in managed care.
- Associate Degree or diploma in Nursing
- 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
- 5 years of experience in clinical education, training and instructional design.
- 2 years work experience in a managed care setting
- 1 year of experience working with Milliman Care Guidelines (MCG), InterQual and/or other clinical criteria/guidelines.
- Preferred Education
- Bachelor's Degree in Nursing or Master’s Degree in Nursing
- Preferred Certifications
- Active and current certifications in the following certifications: Certified Case Manager (CCM) or Utilization Management Certification
- Preferred Certifications
ESSENTIAL job functions AND RESPONSIBILITIES
- The Clinical Auditor is responsible for supporting the supporting the UM vendor. This includes monthly calibration audits (or more frequent per business need), administrative review of policies and procedures for Health Plan UM Vendors, Plan Partners, and other entities, if necessary, to ensure compliance with vendor contract and collaborate with compliance and Quality teams on local, State, Federal and National Committee on Quality Assurance (NCQA) regulations, statues and guidelines.
- Preparing the audit findings, documentation of deficiencies as well as developing final analysis reports for internal and external UM Department Leadership.
- Developing Compliance Department corrective action plans to address deficiencies identified by other departments conducting programmatic level audits. The position collaborates with the Quality Improvement and Accredidation, Medicare Operations, Compliance and other departments as needed to ensure Compliance and quality.
- Conducts monthly audits to measure documentation quality, performance and compliance. Audits include regulatory, procedural and clinical components to be audited. Collaborates with UM leadership to implement and monitor individual CAPs and/or PIPs as necessary.
- Generate weekly and monthly workload reports as required for internal management
- Maintain and update documentation for all relevant policy and procedures, desktop procedures, and any other relevant documents used by vendor(s) for ongoing processes
- Partner with vendor(s) and BCBSAZ internal areas to develop and maintain productivity strategies and measures.
- Work with the appropriate area management to develop and implement monthly, quarterly and YTD reporting processes to track and measure goals/productivity
- Maintain and modify, as necessary, any existing reports and new reports as needed to analyze data; perform root cause analysis to identify potential issues for provider education
- Function as the data expert for vendor(s) to assist management with emerging challenges and measurement needs
- Performs independent high level and detailed analyses to identify patterns and trends that do not support desired results and be able to convey results of research or analysis to all audiences and answer all questions
- Perform analysis and provide necessary business requirements to support changes to any reporting for vendor(s)
- Define and establish business rules and data measurement policies. Provide education of these policies to internal customers and vendor(s)
- Responsible for URAC Delegation Analysis and ongoing reporting. Maintain URAC Training Documentation
- Demonstrate and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals
- Develop and maintain training documentation or provide necessary support and input to areas supporting training efforts
- Work with internal areas to develop and coordinate materials for webinars as requested by management
- Work with internal BCBSAZ departments on educational material and coordination of their deliverables
- Responsible for staying abreast of product/member/provider issues, legislation, CMS mandates, policy changes and system changes so they can be considered for training topics
- Act as a "change agent", constantly challenging conventional thinking, approach, and ways of performing processes
- Research business processes to define or interpret new or additional opportunities for data utilization
- Perform root cause analysis to identify continuous process improvements and to improve provider satisfaction. Demonstrate initiative and resourcefulness in achieving goals and tasks as related to the divisions objectives
- Meet deadlines in required timeframe established by management
- Actively participate in the employee engagement process
- Perform monthly Quality Reviews and provide feedback on staff assigned Inquiries
- Provides coaching to staff for targeted areas needing improvement based on QC audit resultsPerforms quality audits and facilitates inter-rater reliability assessments to ensure standardization and consistency with clinical decisions.
- 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 written and verbal communications. Excellent organizational skills and strong attention to detail
- High level of personal accountability and integrity
- Ability to gather, analyze data and prepare informative and accurate reports.
- Ability to understand the workflow of multiple components of the company and to assist in the creation and implementation of integrated policies, procedures, workplans and creative solutions.
- Intermediate skill in use of office equipment including copier, fax machine, scanner and telephones
- Advanced PC proficiency
- Advanced word processing, excel and database software
- Full understanding of UM for Medicare and Commercial Lines of business.
- Good working knowledge of regulatory requirements/standards.
Required Professional Competencies
- Ability to develop, organize, motivate, coordinate and collaborate effectively with stakeholders from multiple business areas across the organization
- Ability to successfully function in an environment characterized by risk taking, rapidly changing market conditions, strong competition and restructuring.
- Strong understanding of the costs/quality challenges of today’s health care environment.
- Knowledge of health and/or patient education and behavior change techniques
- Organizational skills to analyze, interpret data, synthesize, evaluate and explain educational concepts, practices and methodologies to staff and transfer data to and from written and verbal medium.
- Ability to maintain confidentiality and privacy
- Advanced knowledge of Adult Learning Theory principles and demonstrated ability to facilitate training that resonates with all learning styles
- Practice interpersonal and active listening skills to achieve customer satisfaction
- Demonstrated organizational skills with the ability to prioritize tasks and work with multiple priorities
- Follow and accept instruction and direction
- Establish and maintain working relationships in a collaborative team environment
- Apply independent and sound judgment with good problem solving skill
- Interpret and translate policies, procedures, programs and guidelines
Required Leadership Experience and Competencies
- Desire and capability to drive toward and achieve high standard of quality and results.
- Mindset geared toward the creation, execution and continuous improvement of clinical benefit management department and programs. Intellectual curiosity and ability to view old problems/issues with a fresh perspective.
- Ability to perform job role duties independently.
- Ability to professionally represent BCBSAZ in the community
- Use available information to focus conversations and meetings
- Use facilitator skills to move a group or team from beginning to end of a process
Preferred Job Skills
- Advanced PC proficiency
- Knowledge of CPT/HCPCs and ICD-10 coding
Preferred Professional Competencies
- Knowledge of managed care, utilization management, and quality management
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