Mgr-Utilization Review

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 Manager, Utilization Review leads the development and strategy for the Utilization Review, Transition of Care (TOC) and Health Risk Assessment (HRA) Departments.  Responsible for all NCQA, state and federal regulatory compliance and adherence. Responsible for overall program effectiveness and operational success through direct involvement and supervision of the UR, TOC and HRA departments’ leadership.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

• At least three years management experience
• At least five years experience in utilization management

Required Education

• Active, current, unrestricted Arizona State Registered Nursing license

Required Licenses

• N/A

Required Certifications

• N/A

PREFERRED QUALIFICATIONS

Preferred Work Experience

• N/A

Preferred Education

• Degree in Nursing from an Accredited Nursing School; Master’s preferred

Preferred Licenses

• N/A

Preferred Certifications

• N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

•  Participate in quality activities to include: reporting and following up on grievances and complaints, participating in quality/performance improvement projects and accreditation activities.
• Develop operational programs and plans
• Identify measures of success and related tactics to achieve
• Identify key operational metrics needed to track progress to measures of success
• Develop budget recommendations for department
• Responsible for managing departmental resources to meet budget targets
• Identify staffing plan and execute to optimize and meet productivity goals
• Ability to analyze key data metrics and adapt operations to achieve success
• Ability to communicate plans and evaluations effectively in verbal and written forms
• Review, revise, and develop policies to ensure consistent practice with regulatory expectations
• Ensure training and education on member eligibility and InterQual Criteria to Utilization Review Nurses following Medicare, Medicaid, and Health Choice policies and procedures
• Maintain daily operational awareness of department function and take action as needed to ensure optimal operations
• Collaborate with the Vice President, Clinical Operations to plan and manage daily operations
• Audit interrater reliability standards per contractual guidelines
• Review criteria with Medical Services staff and Medical Director(s) at least annually and update as needed
• Provide guidance and direction to departmental leaders
• Develop and execute processes to promote professional growth and development for leaders and staff
• Evaluate staff using behavioral and performance-based measures
• Manage and monitor unplanned turnover and adapt to maintain minimal levels
• Maintain day-to-day staffing coverages for all departmental functions
• Achieve clinical and financial objectives
• Set example of proper behavior and accountability to employees and serve as a role model for what is expected of a Health Choice employee
• Responsible for all facets of departments regulatory and accreditation process
• Collaborate with quality, compliance, and regulatory leadership as needed
• Ensure all activities, documentation, and evidence necessary for the accreditation are prepared in compliance with accreditation standards
• Contribute to D-SNP Model of Care and AHCCCS annual plans
• Implement and monitor tracking system of Health Choice UM services, documentation and data
• Develop and implement QM indicators for UM in coordination with the Director of Health Choice Quality Management
• Report QM results to appropriate Health Choice departments and the state regulatory agency
• Assist QM Director or designee on monitoring and improving the delivery of services to Health Choice members
• Ensure the TOC program contacts members within three business days of discharge from an acute care setting and that staff:
  • Complete TOC surveys
  • LACE tool utilized
  • Facilitate members with discharge orders, including medications, DME, PT/OT, follow up PCP appointment
  • Medication reconciliation for Medicare members
• Ensure the HRA program completes HRAs, ICPs, and ICTs for D-SNP beneficiaries within 90 days of their initial enrollment and every year thereafter including:
  • Utilize all HRA surveys within Care Radius
  • Completing the HRA from mail backs, telephonically or from electronic feeds
  • Utilizing risk stratification if unable to reach member
• Identify gaps in care and address with members
• Completing individualized care plans
• Collaborating with the interdisciplinary care team
• Referral to care management as appropriate
• The position has an onsite expectation 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

COMPETENCIES

REQUIRED COMPETENCIES

Required Job Skills

• Microsoft Office, including Word, Excel, Outlook
• Ability to generate pivot tables in excel from data

Required Professional Competencies

• N/A

Required Leadership Experience and Competencies

• N/A

PREFERRED COMPETENCIES

Preferred Job Skills

• N/A

Preferred Professional Competencies

• N/A

Preferred Leadership Experience and Competencies

• N/A

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.