Role Description 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 - 2 year(s) of experience in full-time equivalent of direct clinical care to the consumer - 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 - 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. - 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). Requirements - 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 - Bachelor's Degree in Nursing or Health and Human Services related field of study - 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. - 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 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. Required Competencies - 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 - 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 - Navigate, gather, input, and maintain data records in multiple system applications 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.