Clinical Accreditation Program Consultant Job at Blue Cross Blue Shield of Arizona (Phoenix)

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

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Clinical Accreditation Program Consultant

Job Responsibility

Requirements

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