Clinical Quality Coordinator QOC RN - Hybrid

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 position is hybrid within the state of AZ only. PURPOSE OF THE JOB 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. REQUIRED QUALIFICATIONS Required Work Experience 2 years of experience in a clinical field of practice, health insurance, or other health care related field Required Education Associate's Degree general field of study, or post high school nursing diploma Required Licenses 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 Preferred Work Experience 2+ years of experience in health insurance field 2+ years of experience processing potential quality inquiries 2 years of Medicare experience Preferred Education Bachelor's Degree in Nursing or related field of study Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES 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. Use clinical knowledge to provide assessment of data contained within medical record. 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 The position has an onsite expectation of 1 day per week and requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements. Perform all other duties as assigned. REQUIRED COMPETENCIES Required Job Skills Intermediate skill in use of office equipment including copier, fax machine, scanner and telephones Intermediate PC proficiency Intermediate skill in word processing, spreadsheet and database software Required Professional Competencies Health care payer business knowledge including processes and operational data and functions that support the business Maintain confidentiality and privacy Capable of investigative and analytical research to make decisions and recommendations based on available information Independent and sound judgment with good problem solving skills Knowledge of managed care, utilization management, and quality management Establish and maintain working relationships with health care providers, members and coworkers Strong verbal and written communication skills and the ability to compose a variety of business correspondence and interact professionally with a diverse groups, executives, managers, and subject matter experts. Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards Ability to Interpret policies, programs and guidelines Establish and maintain working relationships in a collaborative team environment Organizational skills with the ability to prioritize tasks and work with multiple priorities Required Leadership Experience and Competencies Ability to use available information to focus project’s scope and identify priorities Ability to coordinate/lead small projects Represent BCBSAZ in the community PREFERRED COMPETENCIES Preferred Job Skills Advanced PC proficiency Knowledge of CPT-4 and ICD coding Knowledge of URAC standards or survey Preferred Professional Competencies Maintains current knowledge of State, Federal, BCBSAZ, and other applicable regulatory/accrediting agency requirements as they apply to department functions Preferred Leadership Experience and Competencies N/A Our Commitment AZ Blue does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group. #J-18808-Ljbffr