RN Supervisor - Prior Authorization - 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.

Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week

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

2 years of direct clinical experience
2 years of experience in utilization review
1 year in same or similar role, experience managing clinical direct reports

Required Education

Associate 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

5 years of managed care/health plan experience
5 years of Medicaid and Medicare experience
1 year NCQA 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.
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

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