Clinical Accreditation Program Consultant - Remote AZ

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

Responsible for supporting the UM/Care Management Department by providing professional oversight with an emphasis on regulatory requirements and those processes related to State, Federal, BCBSAZ, Accreditation and Medicare. This position will also lead and coordinate or participate in the processes of initial delegation and ongoing oversight of delegated entities. The position will coordinate or participate in the Delegation Committee to assure multi-department compliance and coordination. Additionally, this position will assist in various aspects of accreditation, delegation, and CMS activities.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

Level 1

• 1 year of experience in clinical and health insurance or other healthcare related field

Level 2

• 2 years of experience in clinical and health insurance or other healthcare related field
• 1 year 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

Level 3

• 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
• 5 years 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.

Required Education

• Associate degree in Nursing or Post High School Nursing Diploma

• 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

• 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

• N/A

• Certified Case Manager (CCM), Certified P