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
Responsible for developing and managing the day to day processes required to provide Care Management (UM and CM) activities that promote quality, cost effective outcomes and remain compliant with all regulatory requirements . This job description includes both utilization management and case management functions with the intent that the manager will be primary in either utilization management or case management.
REQUIRED QUALIFICATIONS
Required Work Experience
- 2 years of experience in full-time equivalent of direct clinical care to the consumer
- 1 year of experience in a supervisory role
Required Education
- Associate’s degree in general field of study or Post High School Nursing Diploma; or Master’s Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D.
Required Licenses
- Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN.
Required Certifications
- Once they have directly supervised the integrated care process within (3) years with the organization, hold a certification in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC).
PREFERRED QUALIFICATIONS
Preferred Work Experience
- 5 years of experience in full-time equivalent of direct clinical care to the consumer or health insurance field
- 2 years of experience in a supervisory role
- 2 years of experience working in a managed care organization
Preferred Education
- Bachelor’s or Master’s Degree in Nursing or Health and Human Services related field of study; or Doctoral degree in behavioral health related field
Preferred Licenses
Preferred Certifications
- Active and current certification in case management from the following certifications; Certified Case Manager (CCM), Certified Disability Management Specialist (CDMS), Case Management Administrator, Certified (CMAC), Case Management Certified (CMC), Certified Rehabilitation Counselor (CRC), Certified Registered Rehabilitation Counselor (CRRC), Certified Occupational Health Nurse (COHN), Registered Nurse Case Manager (RN, C), or Registered Nurse Case Manager (RN,BC).
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
- Manage and oversee all staff activities related to the development and delivery of health improvement/management programs for members with both complex and chronic health care needs.
- Promotes the integrated, whole-person approach to a continuum of care.
- Provide oversight and recommendations on the cases being managed through any of the programs.
- Direct all activities required to maintain accreditation for Case and Utilization Management.
- Responsible for monitoring and reporting department and program performance measures including IRR. – makes recommendations for improvements to operational practices based on the results.
- Evaluate, interpret, and negotiate applicable benefit and regulatory requirements.
- Identify, research, process, resolve and respond to customer inquiries and correspondence via telephone, written communication and/or in person.
- Responsible for the review, update and accuracy of documentation, computer files, policies and procedures related to the departmental goals and objectives – makes recommendations for improvements to operational practices based on the
- Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and implement operational changes and process improvement.
- Keep status of unit current in accordance with service standards, systems, procedures, forms and manuals through staff meetings, verbal, and written communications.
- Provide current case management resources and pertinent clinical resources.
- Facilitate opportunities for staff training, continuing education, and development such as identifying needs, developing curriculum, delivering, and coordinating training. This includes clinical decision making and critical thinking related to member’s care.
- Ensure that updates related to organizational goals and organizational changes are communicated to staff.
- Perform a formal evaluation of job performance per Blue Cross Blue Shield of Arizona (BCBSAZ) corporate policy to include review and assessment of the CM program documentation produced by the Care Management staff members.
- Obtain feedback on support staff job performance from care managers who receive direct support from, and interact on a regular basis
- Interview, evaluate and make recommendations regarding employment decisions.
- Participate in continuing education and current developments in the field of medicine, behavioral health, social determinants, and managed care at least annually.
- The position has onsite expectations of 2 days per week and 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.
REQUIRED COMPETENCIES
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
- Maintain confidentiality and privacy in consideration of State, Federal, BCBSAZ and other accreditation requirements
- Advanced and current clinical knowledge
- Demonstrates knowledge and understanding of the medical management process
- Analytical knowledge necessary to generate reports based on available data and the ability to make decisions based on reported data
- Capable of investigative and analytical research
- Practice interpersonal and active listening skills to achieve customer satisfaction
- Compose a variety of business correspondence
- Interpret and translate policies, procedures, programs and guidelines
- Navigate, gather, input and maintain data records in multiple system applications
- Establish and maintain working relationships in a collaborative team environment with all BCBSAZ Departments/Divisions
- Organizational skills with the ability to prioritize tasks and work with multiple priorities
- Independent and sound judgement with good problem solving skills
Required Leadership Experience and Competencies
- Make use of employee's skills and abilities to deliver business objectives
- Use available information to focus team's activities and identify priorities
- Ability to develop and build a high performing team culture
PREFERRED COMPETENCIES
Preferred Job Skills
Preferred Professional Competencies
- Maintains current knowledge of State, Federal, BCBSAZ, and other applicable regulatory/accrediting agency requirements as they apply to department functions
- Working knowledge of McKesson Interqual® , Milliman Care Guidelines, ASAM or other nationally recognized medical necessity criteria
Preferred Leadership Experience and Competencies
- Demonstrates effective presentation skills
- Demonstrated effective leadership skills