Clinical Quality Coordinator QOC RN

Blue Cross Blue Shield of Arizona•Phoenix, AZ

1d•Hybrid

About The Position

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.

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 (a state in the United States) as a Registered Nurse
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
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
Ability to use available information to focus project’s scope and identify priorities
Ability to coordinate/lead small projects
Represent BCBSAZ in the community

Nice To Haves

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

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.
Perform all other duties as assigned.