Registered Nurse Clinical Quality Coordinator, Phoenix, AZ
Job Title Registered Nurse Clinical Quality Coordinator (prior experience in Healthcare QPI's preferred)
Job ID 4988
Full/Part Time Full-Time
Blue Cross Blue Shield of Arizona is a local, independent Blue Cross Blue Shield Association and a not-for-profit health insurance company headquartered in Phoenix. Founded in 1939, the company has more than 1,400 dedicated employees throughout its Phoenix, Tucson, Chandler and Flagstaff offices. Providing health insurance products, services and networks to more than 1 million Arizonans, Blue Cross Blue Shield of Arizona offers various health plans for individuals, families, and small and large businesses. Blue Cross Blue Shield of Arizona also offers Medicare supplement plans to individuals over age 65.
Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering 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 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.
- Receive and document complaints received regarding potential quality of care concerns.
- Conduct clinical review of complaints received to determine whether a quality of care concern existings.
- 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 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 Work Experience
- 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
Preferred Work Experience
- 2+ years of experience in health insurance field
- 2+ years of experience processing potential quality inquiries
- Bachelor's Degree in Nursing or related field of study
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 reommendations 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
BCBSAZ 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.