Job Description
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.
Responsible for promoting continuity of care through a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates care options and services available to members through their benefit plan that meet the individuals' health care needs while promoting quality, cost effective outcomes. This job description is primary for case management functions but can assist with utilization management if a business need arises. This position is hybrid within the state of AZ only.
Qualifications
REQUIRED QUALIFICATIONS
Required Work Experience
- Minimum 2 year(s) of experience in full-time equivalent of direct clinical care to the consumer
Required Education
Post High School Nursing Diploma or Associate’s Degree in Nursing or BSN or MSN. Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M. Ed.), Ph.D. or Psy. D.Required Licenses
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a health professional, including RN, independent license in the behavioral health profession such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D).Required Certifications
Within 4 years of hire as a Care Manager employee must hold a certification in case management : Certified Case Manager (CCM)PREFERRED QUALIFICATIONS
Preferred Work Experience
3 year(s) of experience in full-time equivalent of direct clinical care to the consumer1-2 year (s) of experience working in a managed care organizationPreferred Education
Bachelor's Degree in Nursing or Health and Human Services related field of studyPreferred Licenses
N / APreferred Certifications
Active and current certification in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC).ESSENTIAL job functions AND RESPONSIBILITIES
Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan.
Answer a diverse and high volume of health insurance related customer calls on a daily basis.Explain to customers a variety of information concerning the organization’s services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc.Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests.Present status reports on all cases to the manager / supervisor and, when indicated, to the medical director.Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements.Maintain complete and accurate records per department policy.Demonstrate ability to apply plan policies and procedures effectively.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.Participate in continuing education and current development in the field of medicine, behavioral health and managed care at least annually.The position 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.competencies
REQUIRED COMPETENCIES
Required Job Skills
Intermediate PC proficiencyIntermediate skill in use of office equipment, including copiers, fax machines, scanner and telephonesIntermediate skill in word processing, spreadsheet, and database softwareRequired Professional Competencies
Maintain confidentiality and privacyAdvanced and current clinical knowledgePractice interpersonal and active listening skills to achieve customer satisfactionInterpret and translate policies, procedures, programs, and guidelinesCapable of investigative and analytical researchDemonstrated organizational skills with the ability to prioritize tasks and work with multiple prioritiesFollow and accept instruction and directionEstablish and maintain working relationships in a collaborative team environmentApply independent and sound judgment with good problem solving skillsNavigate, gather, input, and maintain data records in multiple system applicationsRequired Leadership Experience and Competencies
Conflict ResolutionRepresent BCBSAZ in the communityPREFERRED COMPETENCIES
Preferred Job Skills
Advanced PC proficiencyKnowledge of CPT and ICD-10 codingPreferred Professional Competencies
Knowledge of managed care, utilization management, and quality managementWorking knowledge of McKesson InterQual, MCG, ASAM, or other nationally recognized criteriaKnowledge of a wide range of matters pertaining to the organizations services and operationsKnowledge of health and / or patient education and behavior change techniquesPreferred Leadership Experience and Competencies
N / A