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 of Maternal Health provides strategic, operational, and clinical leadership for maternal health programs serving the Medicaid population. This role is accountable for ensuring member access to timely prenatal and postpartum care; promoting family planning and preventive services; improving quality outcomes; and ensuring effective coordination of care across providers, community partners, and internal teams. QUALIFICATIONS REQUIRED QUALIFICATIONS Required Work Experience 5 years of experience in clinical care 5 years of experience with the maternal health population 3 years of prior supervisory and/or management experience Required Education High School Diploma or GED in general field of study Required Licenses Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN), physician or physician's assistant 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 Care management experience Health plan experience Behavioral health experience Program development experience Knowledge of NCQA and/or URAC health plan standards, AHCCCS, and CMS regulatory requirements Preferred Education Bachelor's or master's degree in nursing or healthcare related field. Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES Provide strategic, operational, and clinical leadership for maternal health programs serving the Medicaid population. Lead the day-to-day operations of the maternal health team, including staffing, coaching, performance management, and professional development. Foster a positive, collaborative, and inclusive team environment that promotes engagement, accountability, and high performance. Oversee maternal health program operations, including: Identification and outreach to pregnant members Pre-authorization of maternity services Care management for high-risk pregnant and postpartum members Transition-of-care support following delivery Newborn verification and coordination of services Ensure timely access to prenatal, postpartum, family planning, and preventive services through effective care coordination. Collaborate with providers, hospitals, community organizations, and internal teams to address the clinical and health‑related social needs of pregnant and postpartum members. Partner with provider organizations to develop and support value‑based care arrangements and effective care coordination processes that improve maternal health outcomes. Build and maintain strong provider and community partnerships to support maternal and infant health outcomes. Set quantitative and qualitative goals for the maternal health program and measure program performance. Monitor program performance, utilization, and outcomes; implement improvements to enhance quality and efficiency. Ensure compliance with all applicable regulatory and accreditation requirements, including NCQA, URAC, AHCCCS, CMS, and other state and federal regulations. Provide training, guidance, and technical assistance to staff and providers to support regulatory compliance, program effectiveness, and best practices in maternal health care. Write and submit required program documentation and reports, including an annual maternity and family planning program description and evaluation. Represent the organization professionally in interactions with internal stakeholders, providers, regulators, and community partners. Ensure the confidentiality of member information and compliance with HIPAA and organizational privacy policies. 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 MS Office, PowerPoint, MS Project, EHR, case management software. Possesses strong clinical background in maternity care with a focus on the delivery of high quality and cost-effective care. Experience working with multiple provider types along the continuum of care, such as physician groups, hospitals, home health agencies, and skilled nursing facilities. Demonstrates ability to problem solve and coach staff when necessary. Previous management experience. Self-motivated and assertive. Demonstrated supervisory and management skills; ability to mentor and lead a staff team. Ability to collaborate with providers and administrators to achieve quality and cost-effective care. Excellent written and verbal communication skills; ability to interact with individuals at all levels within an organization. Requisite poise, judgment, and trustworthiness to represent the Blue Cross Blue Shield of Arizona to internal and external groups. Maintains information in a confidential manner according to policy. Required Professional Competencies N/A Required Leadership Experience and Competencies N/A PREFERRED COMPETENCIES Preferred Job Skills Thorough understanding of health plan and regulatory rules and policies, including NCQA and URAC; understanding of utilization management criteria (e.g. InterQual); understanding of provider delegated relationships with health plans. Thorough understanding of managed care, care management, and referral/authorization operations and principles. Recent patient care management experience, as well as excellent leadership, team building, and communication skills. 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.
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 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 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. QUALIFICATIONS REQUIRED QUALIFICATIONS Required Work Experience 2 year(s) of experience in full-time equivalent of direct clinical care to the consumer 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 Within 4 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). PREFERRED QUALIFICATIONS Preferred Work Experience 3 year(s) of experience in full-time equivalent of direct clinical care to the consumer (managed care CM experience preferred) 1-2 year (s) of experience working in a managed care organization Preferred Education Bachelor's Degree in Nursing or Health and Human Services related field of study Preferred Licenses N/A 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 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 organization’s 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. Participate in continuing education and current development in the field of medicine, behavioral health and managed care at least annually. The position has an onsite expectation of 0 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. Perform all other duties as assigned. COMPETENCIES REQUIRED COMPETENCIES 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 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 priortize 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 Navigate, gather, input, and maintain data records in multiple system applications Required Leadership Experience and Competencies Conflict Resolution Represent BCBSAZ 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 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 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.
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 RN Prior Authorization Supervisor is responsible for overseeing the daily operations of the prior authorization team for the Medicaid Segment which includes Medicaid, ,Medicare Advantage / Dual Eligible Special Needs Plan (D-SNP), and may include Affordable Care Act (ACA) members. The supervisor ensures the clinical team meets the quality and productivity standards, follows policies and procedures, and complies with all BCBSAZ Health Choice regulatory requirements. The supervisor maintains and/or creates desktop procedures for effective workflows and participates in policy oversight with leader. The supervisor provides coaching, feedback, and training to the clinical staff, and manages escalation issues and complex cases. The supervisor will provide support to the clinical staff accountable for the the Notice of Action (NOA) process. The supervisor will provide support to the nonclinical paraprofessionals which include Prior Authorization (PA) and may include NOA technicians, assisting in overall department initiative and training of both clinical and nonclinical staff. Qualifications REQUIRED QUALIFICATIONS Required Work Experience 3 years of direct clinical experience 3 years of experience in utilization review 3 years of in same or similar role, experience managing clinical direct reports Required Education High-School Diploma or GED in general field of study Required Licenses Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse ( RN ) Required Certifications N/A PREFERRED QUALIFICATIONS Preferred Work Experience 5 years of managed care/health plan experience 5 years of Medicaid and Medicare experience Preferred Education Bachelor of Science in Nursing or Healthcare management field of study Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL job functions AND RESPONSIBILITIES Ensures completion, accuracy and timeliness of medical, dental, Pharm D, and behavioral health authorization reviews to meet contractual requirements and ensures all reviews are conducted using InterQual or BCBSAZ Health Choice Clinical Policies. Ensures completion, accuracy, timeliness of NOA letters; member and provider notification. Supervises the prior authorization team, which consists of RNs and LPNs, who review and process prior authorization requests for services and items for the Dual Eligible Special Needs Plan (D-SNP),, Arizona Health Care Cost Containment System (AHCCCS), and possibly ACA commercial members. Monitors clinical teams’ performance and productivity and provide regular reports and feedback to the management. Ensures clinical team adheres to the clinical guidelines, criteria, and protocols, and follows the best practices and standards of care. Ensures clinical team complies with Centers for Medicare and Medicaid (CMS), National Committee for Quality Assurance (NCQA), Arizona Health Care Cost Containment System (AHCCCS), and Utilization Review Accreditation Commission (URAC), and plan-specific regulations and policies, and maintains effective documentation and records accordingly. Coordinates with requesting and servicing practitioners, members, and other internal departments to facilitate the prior authorization process and resolve any issues or concerns. Manages escalated cases, complex situations and provide clinical guidance and support to the clinical staff. Identifies and implement opportunities for improvement and innovation in the prior authorization process and workflow. Develops orientation onboarding and conduct training for new and existing staff and evaluate their competency and skills. Participates in quality improvement initiatives, audits, and compliance reviews. Performs other duties as assigned. competencies REQUIRED COMPETENCIES Required Job Skills Knowledge of InterQual Criteria Set Computer documentation skills to include MS applications, Word, Adobe, Excel and Outlook Communication skills: oral and written Required Professional Competencies Knowledge of and skill with clinical review and medical necessity determinations Required Leadership Experience and Competencies 3-5 years Supervisor experience in Prior Authorization/Utilization Review 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.
