Blue Cross Blue Shield of Arizona
Phoenix, Arizona, United States
Pediatric Integrated Care Manager - (Hybrid)
Job Description
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.
This position is remote within the state of AZ only. This remote work opportunity requires residency, and work to be performed, within the State of Arizona.
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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 that meet the individuals' health care needs while promoting quality, cost effective outcomes. This job description is primary for case management functions but can assist with utilization management if a business need arises.
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Required Qualifications
1. Required Work Experience
2 year(s) of experience in full-time equivalent of direct clinical care
2. Required Education
Associates Degree in general field of study or Post High School Nursing Diploma or Masters Degree in a behavioral health field of study (i.e., MSW, MA, MS, M.Ed.), Ph.D. or Psy.D
3. 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.
4. Required Certifications
Within 3 years of hire as a Care Manager employee must 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).
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PREFERRED QUALIFICATIONS
1. Preferred Work Experience
3 year(s) of experience in full-time equivalent of direct clinical care to the consumer
1-2 year (s) of experience working in a managed care organization
2. Preferred Education
Bachelor's Degree in Nursing or Health and Human Services related field of study
3. Preferred Licenses
N/A
4. 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).
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ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
Assess and collect data related to the member from all care settings. Interview and collaborate with case-related providers, member and family to implement the care plan.
Answer a diverse and high volume of health insurance related customer calls on a daily basis.
Explain to customers a variety of information concerning the organizations services, including but not limited to, contract benefits, changes in coverage, eligibility, claims, BCBSAZ programs, provider networks, etc.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of benefit requests.
Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director.
Consult and coordinate with various internal departments, external plans, providers, businesses, and government agencies to obtain information and ensure resolution of customer inquiries.
Meet quality, quantity and timeliness standards to achieve individual and department performance goals as defined within the department guidelines.
Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements.
Maintain complete and accurate records per department policy.
Demonstrate ability to apply plan policies and procedures effectively.
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.
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Participate in continuing education and current development in the field of medicine, behavioral health and managed care at least annually.
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.
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Perform all other duties as assigned.
COMPETENCIES
REQUIRED COMPETENCIES
1. Required Job Skills
Intermediate PC proficiency
Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones
Intermediate skill in word processing, spreadsheet, and database software
2. Required Professional Competencies
Maintain confidentiality and privacy
Advanced and current clinical knowledge
Practice interpersonal and active listening skills to achieve customer satisfaction
Interpret and translate policies, procedures, programs, and guidelines
Capable of investigative and analytical research
Demonstrated organizational skills with the ability to prioritize tasks and work with multiple priorities
Follow and accept instruction and direction
Establish and maintain working relationships in a collaborative team environment
Apply independent and sound judgment with good problem solving skills
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Navigate, gather, input, and maintain data records in multiple system applications
3. Required Leadership Experience and Competencies
Conflict Resolution
Represent BCBSAZ in the community
PREFERRED COMPETENCIES
1. Preferred Job Skills
Advanced PC proficiency
Knowledge of CPT 2018 and ICD-10 coding
2. Preferred Professional Competencies
Knowledge of managed care, utilization management, and quality management
Working knowledge of McKesson InterQual, MCG, ASAM, or other nationally recognized criteria
Knowledge of a wide range of matters pertaining to the organizations services and operations
Knowledge of health and/or patient education and behavior change techniques
3. Preferred Leadership Experience and Competencies
N/A
CORPORATE RESPONSIBILITIES
Comply with BCBSAZ corporate and departmental policies and procedures, including, but not limited to Code Blue, Compliance, HIPAA, Computer Responsibility, Accreditation Standards, Attendance, Staff Qualifications and Quality Management Accountabilities.
Our Commitment
AZ Blue 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.
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.