Staff VP - Medicaid Clinical Operations (hybrid)

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue 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.

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements:

• Hybrid People Leaders: must reside in AZ, required to be onsite at least once per week

• Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month

• Onsite: daily onsite requirement based on the essential functions of the job

• Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building

Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per month.

This position requires work and residency within the state of Arizona.

Purpose of the job

Responsible for the management and oversight of Clinical Operations within the Medicaid business segment of BCBSAZ to include, but not limited to, prior authorization, care management, medical claims review, medical management, utilization management, transition of care, clinical training and accreditation. The Clinical Operations operate through an integrated care model to ensure compliance with all regulatory agencies and accrediting organizations. Evaluates and ensures organizational clinical programs and resources are used appropriately and effectively, and oversees the collection, analysis, and reporting of financial and clinical data related to performance improvement activities. Accountable for achieving established performance targets through actively engaging multiple disciplines and professional staff and has responsibilities for managing people, relationships, and processes in order to achieve maximized results. Ensures the clinical operations department achieves its goals and objectives by engaging with internal and external stakeholders, and clinical leaders across BCBSAZ. Promotes interdisciplinary collaboration, fosters teamwork across the organization, and champions performance improvement and goal achievement.

REQUIRED QUALIFICATIONS

Required Work Experience

• 7-10 years of experience in the healthcare industry in a leadership role
• 5 years of experience with Medicaid Clinical Operations
• 5 years of experience with accreditation standards

Required Education

• Bachelor’s degree in nursing, business administration, public health, public administration, health care administration, management, finance, or related field.

Required Licenses

• Active, current, and an unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, Board Certified Physician or other Licensed and Certified Provider such as Nurse Practitioner or Physician Assistant; Primary Care Specialty preferred but not necessary. Current Licensure Required
• If the selected candidate does not possess an Arizona license, they are required before their date of hire to obtain a temporary valid unrestricted Arizona license to practice, while they work to obtain their Arizona license.

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 10 years of experience in the healthcare industry in a leadership role
• 5 years of experience with Arizona’s Medicaid Health Plan known as AHCCCS
• 5 years of experience with NCQA accreditation standards
• Experience in health care management and process improvement skills (LEAN, Six Sigma, or equivalent)

Preferred Education

• Master’s degree in nursing, business administration, public health, public administration, health care administration, management, finance, or related field.

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL job functions AND RESPONSIBILITIES

• Responsible for directing Clinical Operations supporting a system-wide Clinically Integrated Network and facilitating cross-business unit collaboration to scale Clinical Operation.
• Responsible for advancing the strategic vision and driving performance.
• Responsible for directing the integration of all clinical functions related to behavioral health and integrated service delivery.
• Work effectively and closely with multiple enterprise teams including the Business Units, Analytics, IT, Performance Teams and Human Resources when developing short- and long-term strategies to drive performance.
• Responsible for the management of clinical operations budgets.
• Lead the development and implementation of effective strategies and compliance regarding maintenance of NCQA (National Committee for Quality Assurance) certification and any other accreditations supporting the business strategy.
• Actively participates in RFI and RFP projects for the success of the business segment and BCBSAZ.
• Drive operational excellence across all Clinical Programs by ensuring Key Performance Indicators are met to achieve budget targets and AHCCCS/CMS requirements, including deliverables.
• Oversees Clinical Programs and participate in shaping overall system strategy driving the highest cost efficient and quality care in the industry.
• Effectively collaborate and inspire highly functioning teams within a complex, fast paced, matrixed organization to shape, implement, and evaluate innovative organizational and service delivery strategies for driving performance.
• Ensure that the clinical operations team understands and is working towards supporting the overall strategic imperatives driving performance for their program and the organization.
• Works closely with Quality Management  communicate medical best practices and guidelines to providers in support of our quality program and contractual obligations.
• Ensure medical management program activities are performed in a cost effective, productive, and timely manner.
• Play a key role as a liaison between providers, hospitals, post-acute care facilities, home care, community partners and any other organization which members may seek care to optimize transition of care.
• Ensure the clinical operations leadership team acts as an internal consultant to other staff as clinical subject matter experts.
• Collaborate with Clinical leaders throughout the segment and within BCBSAZ.
• Review audits, utilization reports, and practice patterns and make recommendations to correct problems identified including chart reviews for coding education.
• Attends meetings with payers and other third-party organizations as needed.
• Assists in the resolution of provider grievances and other clinical provider service issues.
• Performs other functions as assigned.

REQUIRED COMPETENCIES

Required Job Skills

• Advanced ability to analyze cost and clinical care outcomes across a variety of care settings.
• Strong knowledge of care management, utilization management, quality, care coordination, and emerging trends

• Proficiency in computer and technology utilization required, including, but not limited to: care management software, Microsoft Office Products (Outlook, Excel, Power Point, Word, Visio)

Required Professional Competencies

• Possess strong clinical background including but not limited to care management, ambulatory and post-acute care settings with focus on the delivery of high quality and cost-effective care.
• Demonstrated expertise in strategic thinking and the ability to create design and implement successful programs.
• Possess strong interpersonal written and oral skills.
• Possess and demonstrates excellent time management skills with proven ability to effectively manage multiple tasks and priorities at one time.
• Demonstrates advanced knowledge of managed care concepts such as Risk Based Contracting, Care Coordinate, Care Management, Transitions of Care, Tele-monitoring.
• Ability to collaborate with multiple providers to provide quality and cost-effective care for at-risk members.
• Requisite poise, judgment, and trustworthiness to represent to internal and external groups.
• Maintains information in a confidential manner according to policy and legal requirements.
• Possess a strong, diverse clinical background including but not limited to care management, ambulatory and post-acute care settings with a focus on the delivery of high quality and cost-effective care.
• Demonstrated expertise in strategic thinking and the ability to create design and implement successful programs.
• Possess strong interpersonal written and oral skills.
• Possess and demonstrates excellent time management skills with proven ability to effectively manage multiple tasks and priorities at one time.
• Demonstrates advanced knowledge of managed care concepts such as Risk Based Contracting, Care Coordinate, Care Management, Transitions of Care, Tele-monitoring.
• Ability to collaborate with multiple providers to provide quality and cost-effective care for at risk members.

Required Leadership Experience and Competencies

• N/A

PREFERRED COMPETENCIES

Preferred Job Skills

• Diverse experience in both behavioral and physical health.

Preferred Professional Competencies

• N/A

Preferred Leadership Experience and Competencies

• Proven track record of managing multiple spans/layers.
• Ability to work successfully in a matrixed environment.

Our Commitment

AZ Blue 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.