Quality Management Nurse – Remote – AZ

R5971 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

This position is responsible for leading and coordinating the clinical quality review process of quality of care concerns. In addition, facilitates the ongoing activities of the Medicare & Medicaid Performance Department to fulfill regulatory requirements. The position also coordinates activities to meet contractual and reporting timeframes, and for anticipating needs as related to established policies and procedures, and the Medicare & Medicaid Performance Plan and assisting with revisions when needed.

QUALIFICATIONS

  REQUIRED QUALIFICATIONS Required Work Experience

• 3 years of experience in Managed Care;
• 3 years of Quality Management experience.

Required Education

• Bachelor's degree in business, nursing, or related area.

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

  PREFERRED QUALIFICATIONS Preferred Work Experience

• 5 years of experience in Managed Care Quality Management

Preferred Education

• Master of Social Work

Preferred Licenses

• N/A

Preferred Certifications

• Certified Professional in Healthcare Quality.

     

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Participate in development, implementation and evaluation of Quality Management programs.
• Investigate Quality of Care Concerns including tracking and root cause analysis.
• Ensure compliance with Corrective Action Plans and Performance Improvement Projects.
• Interface with regulatory agencies as necessary to ensure compliance with regulations.
• Monitor provider performance through administrative data and medical record review.
• Participate in Quality Management and Peer Review committees.
• Assist in the development of the Quality Management Program Description.
• Assist in the development of the Quality Management Work Plan and annual evaluation.
• Conduct audits of delegated entities as required by regulations.
• Act as Subject Matter Expert on Quality Management.
• Demonstrate and maintain current working knowledge of the required BCBSAZ systems, procedures, forms and manuals.
• Maintain all standards in consideration of State, Federal, 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 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 organizational skills
• Detailed knowledge of Medicare Managed Care
• Proficiency with Microsoft office suite applications (Outlook, Access, Excel)
• Knowledge of Medicare Managed Care including supporting processes, operational data and functions

Required Professional Competencies

• Maintain confidentiality and privacy
• Analytical knowledge to research and make decisions based on available information to complete activities
• Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards
• Interpret and translate policies, procedures, programs and guidelines.
• Establish and maintain working relationships in a collaborative team environment.
• Independent and sound judgment with good problem-solving skills.
• Strong written and verbal communications
• Ability to use available information to focus project’s scope and identify priorities.
• Ability to work with business unit managers in a partnership setting
• Effective presentation skills

Required Leadership Experience and Competencies

• N/A

    PREFERRED COMPETENCIES Preferred Job Skills

• N/A

Preferred Professional Competencies

• Knowledge of information systems including Microsoft office suite, plus public, and proprietary software applications.
• Project Management
• Knowledge of a variety of software applications to manage HEDIS® project.
• Project 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.