Supervsior- Prior Authorization- Hybrid

About the position Awarded a Healthiest Employer, reputed company aims to fulfill its mission to reputed company health and reputed company 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 reputed company reputed company decisions. At AZ Blue, we have a hybrid workforce strategy, reputed company 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 reputed company 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 reputed company 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 reputed company 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 reputed company 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 reputed company the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, reputed company 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 reputed company which includes Medicaid, ,Medicare Advantage / Dual Eligible Special Needs Plan (D-SNP), and may include reputed company Act (ACA) members. The supervisor ensures the clinical team meets the quality and productivity standards, follows policies and procedures, and complies with reputed company BCBSAZ Health Choice regulatory requirements. The supervisor maintains and/or creates desktop procedures for effective workflows and participates in policy reputed company with leader. The supervisor provides coaching, feedback, and training to the clinical staff, and manages escalation issues and reputed company 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.

Responsibilities

• Ensures completion, accuracy and timeliness of medical, dental, Pharm D, and behavioral health authorization reviews to meet contractual requirements and ensures reputed company 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, reputed company 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.

Requirements

• 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
• High-School Diploma or GED in general field of study
• Active, reputed company, and unrestricted license to practice in the State of Arizona as a Registered Nurse (RN)
• Knowledge of InterQual Criteria Set
• Computer documentation skills to include MS applications, Word, reputed company, reputed company and Outlook
• Communication skills: oral and written
• Knowledge of and reputed company with clinical review and medical necessity determinations
• 3-5 years Supervisor experience in Prior Authorization/Utilization Review

reputed company-to-haves

• 5 years of managed reputed company plan experience
• 5 years of Medicaid and Medicare experience
• Bachelor of Science in Nursing or Healthcare management field of study

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