Inspiring Health in Arizona for over 80 years.
Clinical Quality Coordinator QOC RN
Location
United States
Posted
30 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Clinical Quality Coordinator QOC RN
Blue Cross Blue Shield of Arizona
Role Description Responsible for quality functions for the health services business unit, which includes processing complaints and providing professional oversight on vendor delegation and quality management activities. Provide clinical and operational analysis and project coordination support/leadership to the Health Services business unit. Qualifications - 2 years of experience in a clinical field of practice, health insurance, or other health care related field - Associate's Degree in general field of study, or post high school nursing diploma - Active, current, and unrestricted license to practice in the State of Arizona as a Registered Nurse Requirements - 2+ years of experience in health insurance field - 2+ years of experience processing potential quality inquiries - 2 years of Medicare experience - Bachelor's Degree in Nursing or related field of study Essential Job Functions and Responsibilities - Receive and document complaints regarding potential quality of care concerns. - Conduct clinical review of complaints received for quality of care concerns. - Document and present cases to Medical Director for clinical review and decision. - Track results of cases presented and outcomes of the clinical reviews. - Review medical records as needed for quality of care and other corporate initiatives. - Meet quality and timeliness standards to achieve individual and departmental performance goals. - Consult and coordinate with various internal departments, external plans, providers, vendors, businesses, and government agencies. - Document and record facts regarding inquiries, correspondences, and projects. - Demonstrate and maintain current working knowledge of required BCBSAZ systems, procedures, forms, and manuals. - Comply with all state and federal regulations for activities performed. - Support oversight of program data collection and create reports to evaluate current programs. - Create and maintain job aids and documentation of processes to maintain URAC accreditation. - 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. - Perform all other duties as assigned. Required Competencies - Intermediate skill in use of office equipment including copier, fax machine, scanner, and telephones. - Intermediate PC proficiency including word processing, spreadsheet, and database software. - Health care payer business knowledge including processes and operational data. - Maintain confidentiality and privacy. - Capable of investigative and analytical research to make decisions and recommendations. - Independent and sound judgment with good problem-solving skills. - Knowledge of managed care, utilization management, and quality management. - Establish and maintain working relationships with health care providers, members, and coworkers. - Strong verbal and written communication skills. - Practice interpersonal and active listening skills to achieve customer satisfaction. - Ability to interpret policies, programs, and guidelines. - Organizational skills with the ability to prioritize tasks and work with multiple priorities. 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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