2+ years of experience processing potential quality inquiries
2 years of Medicare experience
Preferred Education
Bachelor's Degree in Nursing or related field of study
Preferred Licenses
N/A
Preferred Certifications
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
Receive and document complaints received regarding potential quality of care concerns.
Conduct clinical review of complaints received for quality of care concerns.
Document and present cases to Medical Director for clinical review and decision.
Track results of cases presented and outcomes of the clinical reviews.
Review medical records as needed for quality of care and other corporate initiatives. Use clinical knowledge to provide assessment of data contained within medical record.
Meet quality and timeliness standards to achieve individual and departmental performance goals as defined within the department guidelines.
Consult and coordinate with various internal departments, external plans, providers, vendors, businesses and government agencies to obtain information to meet departmental projects and goals.
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.
Comply with all state and federal regulations for activities performed.
Support oversight of program data collection and create reports to evaluate current programs.
Create and Maintain: Job aids
Documentation of processes to maintain URAC accreditation
When indicated to assist with team/project functions
Collaborate with team to distribute workload/work tasks
Monitor and report team tasks
Communicate team issues and opportunities for improvement to supervisor/manager
Support/mentor team members
The position has an onsite expectation of 1 day per week and 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 COMPETENCIES
Required Job Skills
Intermediate skill in use of office equipment including copier, fax machine, scanner and telephones
Intermediate PC proficiency Intermediate skill in word processing, spreadsheet and database software
Benefits
Health insuranceRemote work options
Additional Information
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 twice per week
Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week
Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): 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 week.
This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona
PURPOSE OF THE JOB
Responsible for quality functions for the health services business unit, which includes processing complaints and providing professional oversight on vendor delegation and quality management activities. Provide clinical and operational analysis and project coordination support/leadership to the Health Services business unit.
REQUIRED QUALIFICATIONS
Required Work Experience 2 years of experience in a clinical field of practice, health insurance, or other health care related field
Required Education
Associate's Degree general field of study, or post high school nursing diploma
Required Licenses
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse
Required Certifications
N/A
Bcbsaz · AZ Blue Phoenix, AZ 85021