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Responsible for quality functions for the health services business unit, which includes processing complaints and providing professional oversight on vendor delegation and quality management activities. Provide clinical and operational analysis and project coordination support/leadership to the Health Services business unit.
Job Responsibility
Receive and document complaints received regarding potential quality of care concerns
Conduct clinical review of complaints received for quality of care concerns
Document and present cases to Medical Director for clinical review and decision
Track results of cases presented and outcomes of the clinical reviews
Review medical records as needed for quality of care and other corporate initiatives
Meet quality and timeliness standards to achieve individual and departmental performance goals as defined within the department guidelines
Consult and coordinate with various internal departments, external plans, providers, vendors, businesses and government agencies to obtain information to meet departmental projects and goals
Document and record facts in regards 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
Comply with all state and federal regulations for activities performed
Support oversight of program data collection and create reports to evaluate current programs
Create and Maintain job aids, documentation of processes to maintain URAC accreditation
When indicated to assist with team/project functions
Collaborate with team to distribute workload/work tasks
Monitor and report team tasks
Communicate team issues and opportunities for improvement to supervisor/manager
Support/mentor team members
Perform all other duties as assigned
Requirements
2 years of experience in a clinical field of practice, health insurance, or other health care related field
Associate's Degree general field of study, 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
2+ years of experience in health insurance field
2+ years of experience processing potential quality inquiries
2 years of Medicare experience
Bachelor's Degree in Nursing or related field of study
Advanced PC proficiency
Knowledge of CPT-4 and ICD coding
Knowledge of URAC standards or survey
Maintains current knowledge of State, Federal, BCBSAZ, and other applicable regulatory/accrediting agency requirements as they apply to department functions