RN Clinical Supervisor, Prior Auth

3 weeks ago

Phoenix, United States Blue Cross Blue Shield of Arizona Full time

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.

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 support the clinical staff accountable for 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

1. 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

• 1 year NCQA experience

2. Required Education

• Bachelor of Science in Nursing or Healthcare management field of study

3. Required Licenses

• Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse (RN)

4. Required Certifications

• N/A

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

• 5 years of managed care/health plan experience

• 5 years of Medicaid and Medicare experience

2. Preferred Education

• N/A

3. Preferred Licenses

• N/A

4. 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

1. 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

2. Required Professional Competencies

• Knowledge of and skill with clinical review and medical necessity determinations

3. Required Leadership Experience and Competencies

• 3-5 years Supervisor experience in Prior Authorization/Utilization Review

PREFERRED COMPETENCIES

1. Preferred Job Skills N/A

2. Preferred Professional Competencies

N/A

3. 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.

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