Registered Nurse-Clinical Compliance Specialist
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 supporting the UM/Care Management Department by providing professional oversight with an emphasis on Medicare Regs and URAC accreditation Health Management System workflow configuration and documentation, Case and Utilization Management , and compliance with State, Federal, BCBSAZ and Accreditation and Medicare requirements.
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:
- Policies for the UM/Care Management Departments
- Documentation of processes to maintain URAC accreditation and Medicare regulations
- Workflow documents for the health management system
- Create and/or update correspondence to be used by Care Management staff or BCBS vendors.
- Development and delivery of training materials to UM/Care Management employees 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 regards 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 Work Experience
1 year Experience in clinical and health insurance or other healthcare related field
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
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’s Degree in general field of study 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 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
- 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 or related field of study
- 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 COMPETENCIESPreferred 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
Preferred Leadership Experience and Competencies
- Project 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