Supervisor, Utilization Review (TOC) - Hybrid

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 Utilization Review Supervisor coordinates the activities of the UR department as they relate to medical necessity reviews, authorizations of inpatient, observation and sub-acute medical levels of care for Medicaid Business Segment members. This position monitors all authorization processes for meeting timeliness standards, cost effectiveness, and regulatory standards. Oversees the Transition of Care team ensuring members are contacted post hospital discharge within regulatory timeframes and member needs are met.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

Required Work Experience

• •2 years of direct clinical experience
• •1 year of experience in utilization review

Required Education

Associate’s Degree 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

• •1 year of managed care/health plan experience
• •1 year of Medicaid and Medicare experience

Preferred Education

Bachelor’s Degree in Nursing or related field of study

Preferred Licenses

N/A

Preferred Certifications

N/A

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

• •Ensures inpatient authorization requests are completed accurately, thoroughly, and in a timely fashion to meet contractual requirements and ensures all reviews are conducted using InterQual.
• •Evaluating statistics on department’s volumes, results, including approvals, denials, turnaround times for department and individual staff.
• •Preparing and delivering reports to department and management staff. Performing audits of case files and staff’s work.
• •Reviewing and updating department’s policies and desktop procedures.
• •Manage day to day activity of assigned team. Directly supervises staff including participating in hiring, monitoring and evaluating performance, timecards, staff training.
• •Complete IRR audits per policy; coach and mentor staff; work with management on employee performance issues.
• •Monitor phone activity and staff productivity. Ensures team meets budget and performance goals.
• •Participates in Quality Improvement Projects.
• •Assists management and others in preparation for audits and other regulatory activities.
• •Participates in interdepartmental meetings and trainings.
• •Perform all other duties as assigned
• •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

• •InterQual
• •Computer skills including MS Word, Excel spreadsheets
• •Communication skills: oral and written

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.