Remote Utilization Management Specialist Jobs

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 remote work opportunity requires residency, and work to be performed, within the State of Arizona.

PURPOSE OF THE JOB

• Responsible for designing, delivering, and evaluating clinical training programs and audit activities that promote standardized clinical decision-making, regulatory compliance and quality improvement across Utilization Management and Care Management initiatives.
• This role supports staff development, onboarding, inter-rater reliability, and ongoing education for clinical teams to enhance performance, operational consistency, and achievement of organizational goals and initiatives.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

• 5 years of direct clinical care experience in a healthcare setting
• 2 years of experience in Utilization Management, Care Management, Health Management, Disease Management, or other managed care operations.
• 4 years of experience in clinical training, education, auditing, or quality improvement, preferably in managed care.

Required Education

• Associate degree in 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) (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC, LMFT, or licensed psychologist (Psy.D. or Ph.D.),or RDN (Registered Dietitian Nutritionist), CDCES (Certified Diabetes Care and Education Specialist), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN, OR an active, current, and unrestricted license to practice in the State of Arizona as an LPN.

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 5 years of experience in clinical education, training, auditing, quality improvement, and instructional design in either Utilization Management or Case Management.
• 1 year of experience working with Milliman Care Guidelines (MCG), and / or other clinical criteria/guidelines.
• Experience conducting clinical audits, quality reviews, or inter-rater reliability assessments related to evidence- based clinical decision making, documentation accuracy, and regulatory or accreditation standards.
• Experience supporting onboarding, staff development, remediation, or performance improvement initiatives for clinical staff.

Preferred Education

• Master’s degree in nursing, Master of Science, Social Work, Behavioral Health, Psychology, or another related clinical field.

Preferred Certifications

• Active and current certifications such as: Certified Case Manager (CCM), Certified Professional in Healthcare Quality (CPHQ), Board Certified Behavior Analyst (BCBA), or a Utilization Management Certification related to evidence-based clinical criteria such as MCG.

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Develop and deliver training and education for clinical staff on clinical philosophy, evidence-based practice, documentation standards, regulatory requirements, and operational workflows related to Utilization Management, Care Management and Health Management.
• Assess and prioritize training needs based on workflow changes, audit findings, stakeholder feedback, business priorities, and staff readiness.
• Evaluate training effectiveness using feedback, knowledge checks, audit trends, and performance data to identify gaps and recommend improvements.
• Assist with the development and evaluation of performance goals, quality management activities, and improvement initiatives that support clinical, operational, and regulatory standards.
• Coordinate onboarding and training readiness activities, including system access, required resources, non-clinical checklists, and resolution of technical barriers.
• Perform quality audits for Utilization Management activities and medical director determinations to evaluate consistency, accuracy, and compliance in evidence-based clinical decision-making, including inter-rater reliability assessments for Utilization Management as applicable. Audit activities assess whether medical director’s determinations are clear, concise, and documented to support clinical reviewers’ understanding and next-step action.
• Perform quality audits for Care Management and Health Management activities to assess accuracy and completeness of documentation, alignment of interventions with care plans, and progression toward member outcomes and goals.
• Support targeted education, remediation, and performance improvement initiatives based on audit findings, operational needs, and quality management priorities.
• Support process improvement initiatives by providing education, workflow guidance, and technical application support to clinical staff and stakeholders.
• Facilitate calibration and standardization activities to support consistent application of clinical criteria, policies, workflows, and documentation expectations.
• Present case status updates and relevant findings to the manager, supervisor, and when indicated, the medical director to support clinical oversight, decision making, and appropriate follow-up.
• Assist with the review, revision, and ongoing maintenance of policies and procedures to ensure alignment with regulatory requirements, organizational standards, and evidence-based clinical practice.
• Assist with ad hoc training assignments and educational initiatives as needed to support departmental priorities, workflow changes, and staff development.
• Maintain compliance with applicable state, federal, AZ Blue, URAC, CMS and other regulatory and accreditation standards.
• Maintain complete, accurate, and timely records in accordance with department policies, procedures, and documentation standards.
• Participate in continuing education and remain current on developments in clinical practice, medicine, managed care, and applicable regulatory requirements.
• Facilitate hands-on technical training for Care Management, Health Management, and Utilization Management workflows, including system navigation, documentation expectations, authorization entry, assessment completion, mock scenarios, and guided practice.
• Develop training plans with learning objectives, workflow scenarios, guided practice, competency checks, and follow up coaching to support readiness for independent work.
• Develop, maintain, version control for training materials, job aids, facilitator guides, and workflow resources to ensure accuracy, consistency, and alignment with current standards.
• Coordinate cross-functional support between IT, new hires, and operational teams to address system access and application issues.
• Facilitate structured onboarding using non-clinical checklists to ensure all requirements are completed.
• Ensure system access readiness by validating functionality, conducting required testing, and verifying availability of tools and resources.
• Utilize training environments to reinforce system proficiency through structured practice, guided navigation exercises, mock scenarios, and hands-on demonstrations of CM, HM, and UM workflows, including assessment completion and authorization entry.
• The position 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.

COMPETENCIES

REQUIRED COMPETENCIES

Required Job Skills

• Strong written and verbal communication skills. Excellent organizational skills and strong attention to detail
• Possess proficient computer and technological skills especially Word, Excel, PowerPoint, SharePoint, Microsoft Teams/Webinar, and Internet
• Ability to gather, analyze data and prepare informative and accurate reports.
• Ability to understand the workflow of multiple components of the company and to assist in the creation and implementation of integrated policies, procedures, workplans and creative solutions.

Required Professional Competencies

• Ability to develop, organize, motivate, coordinate, and collaborate effectively with stakeholders from multiple business areas across the organization.
• Ability to successfully function in an environment characterized by risk taking, rapidly changing market conditions, strong competition and restructuring.
• Strong understanding of the costs/quality challenges of today’s health care environment.
• Knowledge of health and/or patient education and behavior change techniques.
• Organizational skills to analyze, interpret data, synthesize, evaluate and explain educational concepts, practices and methodologies to staff and transfer data to and from written and verbal medium.
• Ability to maintain confidentiality and privacy
• Advanced knowledge of Adult Learning Theory principles and demonstrated ability to facilitate training that resonates with all learning styles
• Demonstrate strong interpersonal and active listening skills
• Demonstrated organizational skills with the ability to priortize tasks and work with multiple priorities
• Follow and accept instruction and direction
• Establish and maintain working relationships in a collaborative team environment
• Apply independent and sound judgment with good problem solving skilll

Required Leadership Experience and Competencies

• Desire and capability to drive toward and achieve high standard of quality and results.
• Mindset geared toward the creation, execution and continuous improvement of clinical benefit management department and programs. Intellectual curiosity and ability to view old problems/issues with a fresh perspective.
• Ability to perform job duties independently.
• Ability to professionally represent AZ Blue in the community

PREFERRED COMPETENCIES

Preferred Job Skills

• Advanced PC proficiency
• Knowledge of CPT/HCPCs and ICD-10 coding

Preferred Professional Competencies

• Knowledge of managed care, utilization management, and quality management

Preferred Leadership Experience and Competencies

• N/A

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.