• 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 remote work opportunity requires residency, and work to be performed, within the State of Arizona.

PURPOSE OF THE JOB

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. Ensures care meets individual healthcare needs while promoting quality and cost-effective outcomes. This role is primarily focused on case management but may assist with utilization management if needed.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

• 2 years of full-time equivalent experience in direct clinical care to consumers

Required Education

• Associate’s Degree in a general field of study OR
• Post High School Nursing Diploma OR
• Master’s Degree in a behavioral health field (MSW, MA, MS, M.Ed.), Ph.D., or Psy.D

Required Licenses

• Active, current, unrestricted license in Arizona (or eligible via endorsement) as a behavioral health professional such as LCSW, LPC, LISAC, LMFT, or licensed psychologist (Psy.D. or Ph.D.) OR
• Active, current, unrestricted RN license in Arizona or a Nurse Licensure Compact (NLC) state

Required Certifications

• Within 4 years of hire, must obtain one of the following case management certifications:

CCM, CDMS, CMAC, CMC, CRC, CRRC, COHN, RN-C, or RN-BC

PREFERRED QUALIFICATIONS

Preferred Work Experience

• 3 years of direct clinical care experience (managed care case management preferred)
• 1–2 years of experience in a managed care organization

Preferred Education

• Bachelor’s Degree in Nursing or Health and Human Services

Preferred Licenses

• None

Preferred Certifications

• Active case management certification (CCM, CDMS, CMAC, CMC, CRC, CRRC, COHN, RN-C, RN-BC)

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• Assess and collect member data from all care settings
• Collaborate with providers, members, and families to implement care plans
• Handle high-volume health insurance-related customer calls daily
• Explain benefits, coverage, eligibility, claims, programs, and networks
• Review medical records and determine medical necessity based on criteria and benefits
• Present case status updates to leadership and medical director as needed
• Coordinate with internal departments, providers, and external agencies
• Meet quality, productivity, and timeliness standards
• Maintain compliance with state, federal, and accreditation requirements
• Ensure accurate and complete documentation
• Apply policies and procedures effectively

Team Support (when applicable)

• Assist in workload distribution
• Monitor and report team progress
• Communicate issues and improvement opportunities
• Mentor and support team members
• Participate in continuing education in healthcare, behavioral health, and managed care annually

Work Schedule

• Full-time role (minimum 40 hours per week)
• Additional hours may be required based on business needs
• Perform other duties as assigned

COMPETENCIES

REQUIRED COMPETENCIES

Required Job Skills

• Intermediate PC skills
• Intermediate use of office equipment (copiers, fax, scanners, phones)
• Intermediate skills in word processing, spreadsheets, and databases

Required Professional Competencies

• Maintain confidentiality and privacy
• Advanced clinical knowledge
• Strong interpersonal and active listening skills
• Ability to interpret and explain policies and procedures
• Strong analytical and research skills
• Organizational skills with ability to manage multiple priorities
• Ability to follow direction
• Team collaboration skills
• Sound judgment and problem-solving ability
• Ability to manage and maintain data across multiple systems

Required Leadership Competencies

• Conflict resolution
• Ability to represent the organization in the community

PREFERRED COMPETENCIES

Preferred Job Skills

• Advanced PC proficiency
• Knowledge of CPT 2018 and ICD-10 coding

Preferred Professional Competencies

• Knowledge of managed care, utilization management, and quality management
• Familiarity with InterQual, MCG, ASAM, or similar criteria tools
• Understanding of organizational services and operations
• Knowledge of patient education and behavior change techniques

Preferred Leadership Competencies

• None

Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.