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INTRODUCTION

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 developing and delivering clinical curriculum, developmental programs and services to assist with achievement of goals and initiatives.
• Responsible for conducting clinical audits and reviews to ensure standardization and consistency with nurse reviewer clinical decisions.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

• 5 years of direct clinical care experience in a healthcare setting
• 2 years of work experience in a managed care setting
• 4 years of clinical training or clinical education experience, preferably in managed care.

Required Education

• Associate Degree or in Nursing

Required Licenses Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN) or Master’s in Social Work (MSW).

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 5 years of experience in clinical education, training and instructional design.
• 1 year of experience working with Milliman Care Guidelines (MCG), InterQual and/or other clinical criteria/guidelines.

Preferred Education Bachelor's Degree in Nursing or Master’s Degree in Nursing

Preferred Certifications Active and current certifications in the following certifications: Certified Case Manager (CCM) or Utilization Management Certification

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Develop and educate clinical staff on the company's clinical philosophy and evidence based practice methods required for excellent patient outcomes and regulatory requirements for care management and utilization management.
• Identify training needs outside of core curriculum to promote maximized effectiveness in managing medical costs and improving clinical outcomes.
• Maintain and monitor the delivery and effectiveness of the training programs, identify solutions to challenges and implement improvements.
• Assist with the development and evaluation of performance goals and objectives and quality management activities.
• Develop and facilitate new hire orientation for the clinical staff and ensure transition of training into daily work activities related to clinical practice, patient safety and evidence-based practice.
• Performs quality audits and facilitates inter-rater reliability assessments to ensure standardization and consistency with clinical decisions.
• Support and provide education with process improvement programs and technical applications.
• Develop programs to support educational needs as determined by management.
• Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director.
• Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements.
• Maintain complete and accurate records per department policy.
• Participate in continuing education and current development in the field of medicine and managed care.
• Facilitate interdisciplinary care round/discussions under the direction of the VP, Clinical Benefit Management and/or delegate.
• 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 communications. Excellent organizational skills and strong attention to detail
• Possess proficient computer and technological skills especially Word, Excel, Powerpoint, SharePoint, Lync/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
• Practice interpersonal and active listening skills to achieve customer satisfaction
• Demonstrated organizational skills with the ability to prioritize 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 skills

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 role duties independently.
• Ability to professionally represent BCBSAZ 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

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. If interested in this position, please apply.