Registered Nurse Clinical Compliance Specialist - healthcare QA exp
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. BCBSAZ 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.
- Responsible for supporting the UM/Care Management Department by providing professional oversight with an emphasis on regulatory requirements and those processes related to State, Federal, BCBSAZ, Accreditation and Medicare. This position will also lead and coordinate or participate in the processes of initial delegation and ongoing oversight of delegated entities. The position will coordinate or participate in the Delegation Committee to assure multi-department compliance and coordination. Additionally, this position will assist in various aspects of accreditation, delegation, and CMS activities.
Required Work Experience
Level I Experience
1 year Experience in clinical and health insurance or other healthcare related field
Level II Experience
2 years Experience in clinical and health insurance or other healthcare related field
1 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, Medical Appeals and Grievance (MAG), Quality Management and/or Accreditation and Medicare requirements
Level III experience
3 years Experience in clinical and health insurance or other healthcare related field
2 years Managed care experience with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, Medical Appeals and Grievance (MAG), Quality Management and/or Accreditation and Medicare requirements
5 years Above satisfactory job performance in the managed care environment with a focus in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, Medical Appeals and Grievance (MAG), Quality Management and/or Accreditation and Medicare requirements.
- Associate degree in Nursing or Post High School Nursing Diploma
- Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse
PREFERRED QUALIFICATIONSPreferred Work Experience
- 3 years of experience in clinical field of practice, health insurance, or other health care related field
- 2 years of experience working on healthcare-related systems
- 2 years of experience in delegation, accreditation, or regulatory environment
- 1 year of experience leading improvement projects
- 1 year of experience in data analysis
- 1 year of experience in accreditation or Medicare Quality Regulations
- Bachelor's Degree in Nursing
- Master’s in Nursing, Public Health or other related field
- Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHQ), Certified Professional in Healthcare Quality, or Certified Managed Care Nursing
ESSENTIAL job functions AND RESPONSIBILITIES
- Develop and document health improvement/management programs for members in compliance with applicable state, federal, accreditation and Medicare regulations.
- Support business processes and data flows and how they affect health management/BCBS processes, systems and other operational areas
- Participate in and/or lead process improvement, quality for accreditation or Medicare improvement projects
- Analyze and/or oversight of program data collection and reports to evaluate current programs.
- Research and analyze procedural problems and provide recommendations for improvements and changes
- Consult and coordinate with various internal departments, external plans, providers, vendors, businesses and government agencies to obtain information to meet departmental projects and goals.
- Create and maintain the following as applicable:
- Policies for the UM/Care Management Departments
- Documentation of processes to maintain URAC accreditation and Medicare regulations
- Responsible for the running or participating in the Delegation Committee. Activities may include scheduling, documentation and retention of all materials per the BCBSAZ guidelines
- Provide and/or monitor and audit all evidence provided by the vendors to ensure complete and gaps are closed.
- Create and/or update correspondence as required per the position.
- Development and delivery of training materials to stakeholders in Accreditation and Regulatory processes.
- Monitor delegated entities for quality and contract requirements and maintain reporting for evaluation and departmental reporting.
- Document and record facts in regard to inquiries, correspondences and projects by updating files and systems.
- Demonstrate and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals.
- Maintain all standards in consideration of State, Federal, FEP, Medicare, BCBSAZ and other applicable regulatory/accrediting agency requirements as they apply to department functions.
- The position requires a full-time work schedule. Full-time is 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
- Intermediate knowledge of information systems including Microsoft office suites plus public and proprietary software applications
- Intermediate knowledge of CPT-4, HCPCS, ICD-9 and ICD-10 coding
Required Professional Competencies
- Health care payer business knowledge including supporting processes, operational data and functions
- Maintain confidentiality and privacy
- Analytical knowledge to research and make decisions based on available information to complete activities
- Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards
- Knowledge of managed care delivery models across the continuum of care
- Compose a variety of business correspondence
- Interpret and translate policies, procedures, programs and guidelines
- Establish and maintain working relationships in a collaborative team environment
- Organizational skills with the ability to prioritize tasks and work with multiple priorities
- Independent and sound judgment with good problem-solving skills
Required Leadership Experience and Competencies
- Ability to use available information to focus project’s scope and identify priorities
- Represent BCBSAZ in the community
- Demonstrate effective presentation skills
Preferred Job Skills
- Advanced knowledge of information systems including Microsoft office suite (excel, visio, word,etc.) plus public and proprietary software applications
- Advanced knowledge of CPT-4, HCPCS, ICD-9 and ICD-10 coding
- Knowledge of URAC standards, survey/or Medicare requirements.
- Knowledge of systems development, database systems, and data management.
Preferred Professional Competencies
- Working knowledge of InterQual® criteria/Milliman Coverage Guidelines
- Knowledge of health management systems
- Advanced systems research and analysis expertise.
- Ability to write test and execute test plans
- Knowledge of business requirements development and user acceptance testing
- Comprehensive knowledge of the following: credentialing, URAC, NCQA, HEDIS,CAHPS, medical policies issues and utilization 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.