Quality Management Nurse - Remote - AZ

Blue Cross Blue Shield of Arizona•Phoenix, AZ

1d•Remote

About The Position

This position is responsible for leading and coordinating the clinical quality review process of quality of care concerns. In addition, it 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.

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 (a state in the United States) as a Registered Nurse
Strong organizational skills
Detailed knowledge of Medicare Managed Care
Proficiency with Microsoft office suite applications (Outlook, Access, Excel)
Knowledge of Medicare Managed Care including supporting processes, operational data and functions
Maintain confidentiality and privacy
Analytical knowledge to research and make decisions based on available information to complete activities
Practice interpersonal and active listening skills to achieve customer satisfaction and departmental communication standards
Interpret and translate policies, procedures, programs and guidelines.
Establish and maintain working relationships in a collaborative team environment.
Independent and sound judgment with good problem-solving skills.
Strong written and verbal communications
Ability to use available information to focus project’s scope and identify priorities.
Ability to work with business unit managers in a partnership setting
Effective presentation skills
Residency, and work to be performed, within the State of Arizona.

Nice To Haves

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.
Project Management

Responsibilities

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.
Perform all other duties as assigned.