Clinical Accreditation Program Consultant - Remote AZ

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 weekHybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per weekHybrid 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 monthOnsite: daily onsite requirement based on the essential functions of the jobRemote: 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 buildingPlease 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 remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOBResponsible 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.QualificationsREQUIRED QUALIFICATIONSRequired Work Experience5 years of 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.3 years of experience in clinical and health insurance or other healthcare related field2 years of 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 Required EducationAssociate degree in Nursing or Post High School Nursing DiplomaRequired LicensesActive, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered NurseRequired CertificationsN/APreferred QualificationsPreferred Work Experience5 years of 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.3 years of experience in clinical field of practice, health insurance, or other health care related field2 years of experience working on healthcare-related systems2 years of experience in delegation, accreditation, or regulatory environment1 year of experience leading improvement projects1 year of experience in data analysis1 year of experience in accreditation or Medicare Quality RegulationsPreferred EducationBachelor's Degree in NursingMaster’s in Nursing, Public Health or other related fieldPreferred LicensesN/APreferred CertificationsCertified Case Manager (CCM), Certified Professional in Healthcare Management (CPHQ), Certified Professional in Healthcare Quality, or Certified Managed Care NursingEssential Job Functions And ResponsibilitiesDevelop 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 areasParticipate in and/or lead process improvement, quality for accreditation or Medicare improvement projectsAnalyze and/or oversight of program data collection and reports to evaluate current programs.Research and analyze procedural problems and provide recommendations for improvements and changesConsult 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 DepartmentsDocumentation of processes to maintain URAC accreditation and Medicare regulationsResponsible for the running or participating in the Delegation Committee. Activities may include scheduling, documentation and retention of all materials per the BCBSAZ guidelinesProvide 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.COMPETENCIESRequired CompetenciesRequired Job SkillsIntermediate knowledge of information systems including Microsoft office suites plus public and proprietary software applicationsIntermediate knowledge of CPT-4, HCPCS, ICD-9 and ICD-10 codingRequired Professional CompetenciesHealth care payer business knowledge including supporting processes, operational data and functionsMaintain confidentiality and privacyAnalytical knowledge to research and make decisions based on available information to complete activitiesPractice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standardsKnowledge of managed care delivery models across the continuum of careCompose a variety of business correspondenceInterpret and translate policies, procedures, programs and guidelinesEstablish and maintain working relationships in a collaborative team environmentOrganizational skills with the ability to prioritize tasks and work with multiple prioritiesIndependent and sound judgment with good problem-solving skillsRequired Leadership Experience And CompetenciesAbility to use available information to focus project’s scope and identify prioritiesRepresent BCBSAZ in the communityDemonstrate effective presentation skillsPreferred CompetenciesPreferred Job SkillsAdvanced knowledge of information systems including Microsoft office suite (excel, visio, word,etc.) plus public and proprietary software applicationsAdvanced knowledge of CPT-4, HCPCS, ICD-9 and ICD-10 codingKnowledge of URAC standards, survey/or Medicare requirements.Knowledge of systems development, database systems, and data management.Preferred Professional CompetenciesWorking knowledge of InterQual® criteria/Milliman Coverage GuidelinesKnowledge of health management systemsAdvanced systems research and analysis expertise.Ability to write test and execute test plansKnowledge of business requirements development and user acceptance testingComprehensive knowledge of the following: credentialing, URAC, NCQA, HEDIS,CAHPS, medical policies issues and utilzation management.Preferred Leadership Experience And CompetenciesProject ManagementOur CommitmentAZ 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.