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Clinical Accreditation Program Consultant

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Blue Cross Blue Shield of Arizona

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Location:
United States , Phoenix

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Category:
IT - Administration

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Contract Type:
Not provided

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Salary:

Not provided
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Job Responsibility:

  • Develop 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 areas
  • Participate in and/or lead process improvement, quality for accreditation or Medicare improvement projects
  • Analyze and/or oversight of program data collection and reports to evaluate current programs.
  • Research and analyze procedural problems and provide recommendations for improvements and changes
  • Consult 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 Policies for the UM/Care Management Departments
  • Create and maintain Documentation of processes to maintain URAC accreditation and Medicare regulations
  • Responsible for the running or participating in the Delegation Committee.
  • Provide 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.
  • Perform all other duties as assigned.

Requirements:

  • 5 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 field
  • 2 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.
  • Associate degree in Nursing or Post High School Nursing Diploma
  • Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse

Nice to have:

  • 5 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 field
  • 2 years of experience working on healthcare-related systems
  • 2 years of experience in delegation, accreditation, or regulatory environment
  • 1 year of experience leading improvement projects
  • 1 year of experience in data analysis
  • 1 year of experience in accreditation or Medicare Quality Regulations
  • Bachelor's Degree in Nursing
  • Master's in Nursing, Public Health or other related field
  • Certified Case Manager (CCM), Certified Professional in Healthcare Management (CPHQ), Certified Professional in Healthcare Quality, or Certified Managed Care Nursing
  • Advanced knowledge of information systems including Microsoft office suite (excel, visio, word,etc.) plus public and proprietary software applications
  • Advanced knowledge of CPT-4, HCPCS, ICD-9 and ICD-10 coding
  • Knowledge of URAC standards, survey/or Medicare requirements.
  • Knowledge of systems development, database systems, and data management.
  • Working knowledge of InterQual® criteria/Milliman Coverage Guidelines
  • Knowledge of health management systems
  • Advanced systems research and analysis expertise.
  • Ability to write test and execute test plans
  • Knowledge of business requirements development and user acceptance testing
  • Comprehensive knowledge of the following: credentialing, URAC, NCQA, HEDIS,CAHPS, medical policies issues and utilzation management.
  • Project Management

Additional Information:

Job Posted:
May 04, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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