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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.
Job Responsibility:
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
Perform all other duties as assigned
Requirements:
3 years of experience in Managed Care
3 years of Quality Management experience
Bachelor's degree in business, nursing, or related area
Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse
Nice to have:
5 years of experience in Managed Care Quality Management
Master of Social Work
Certified Professional in Healthcare Quality
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