Supervsior- Prior Authorization- Hybrid

Blue Cross Blue Shield of Arizona•Tampa, FL

4d•Hybrid

About The Position

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 position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona. Purpose of the job The RN Prior Authorization Supervisor is responsible for overseeing the daily operations of the prior authorization team for the Medicaid Segment which includes Medicaid, ,Medicare Advantage / Dual Eligible Special Needs Plan (D-SNP), and may include Affordable Care Act (ACA) members. The supervisor ensures the clinical team meets the quality and productivity standards, follows policies and procedures, and complies with all BCBSAZ Health Choice regulatory requirements. The supervisor maintains and/or creates desktop procedures for effective workflows and participates in policy oversight with leader. The supervisor provides coaching, feedback, and training to the clinical staff, and manages escalation issues and complex cases. The supervisor will provide support to the clinical staff accountable for the the Notice of Action (NOA) process. The supervisor will provide support to the nonclinical paraprofessionals which include Prior Authorization (PA) and may include NOA technicians, assisting in overall department initiative and training of both clinical and nonclinical staff.

Requirements

3 years of direct clinical experience
3 years of experience in utilization review
3 years of in same or similar role, experience managing clinical direct reports
High-School Diploma or GED in general field of study
Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse (RN)
Knowledge of InterQual Criteria Set
Computer documentation skills to include MS applications, Word, Adobe, Excel and Outlook
Communication skills: oral and written
Knowledge of and skill with clinical review and medical necessity determinations
3-5 years Supervisor experience in Prior Authorization/Utilization Review

Nice To Haves

5 years of managed care/health plan experience
5 years of Medicaid and Medicare experience
Bachelor of Science in Nursing or Healthcare management field of study

Responsibilities

Ensures completion, accuracy and timeliness of medical, dental, Pharm D, and behavioral health authorization reviews to meet contractual requirements and ensures all reviews are conducted using InterQual or BCBSAZ Health Choice Clinical Policies.
Ensures completion, accuracy, timeliness of NOA letters; member and provider notification.
Supervises the prior authorization team, which consists of RNs and LPNs, who review and process prior authorization requests for services and items for the Dual Eligible Special Needs Plan (D-SNP),, Arizona Health Care Cost Containment System (AHCCCS), and possibly ACA commercial members.
Monitors clinical teams’ performance and productivity and provide regular reports and feedback to the management.
Ensures clinical team adheres to the clinical guidelines, criteria, and protocols, and follows the best practices and standards of care.
Ensures clinical team complies with Centers for Medicare and Medicaid (CMS), National Committee for Quality Assurance (NCQA), Arizona Health Care Cost Containment System (AHCCCS), and Utilization Review Accreditation Commission (URAC), and plan-specific regulations and policies, and maintains effective documentation and records accordingly.
Coordinates with requesting and servicing practitioners, members, and other internal departments to facilitate the prior authorization process and resolve any issues or concerns.
Manages escalated cases, complex situations and provide clinical guidance and support to the clinical staff.
Identifies and implement opportunities for improvement and innovation in the prior authorization process and workflow.
Develops orientation onboarding and conduct training for new and existing staff and evaluate their competency and skills.
Participates in quality improvement initiatives, audits, and compliance reviews.
Performs other duties as assigned.