- Associate's Degree
- Bachelor's Degree
- Utilization Management
- Instructional Design
- Leadership Experience
- Computer Skills
Responsible for developing and delivering clinical curriculum, developmental programs and services to assist with achievement of goals and initiatives. Responsible for conducting clinical audits and reviews to ensure standardization and consistency with nurse reviewer clinical decisions Develop and educate clinical staff on the company's clinical philosophy and evidence based practice methods required for excellent patient outcomes and regulatory requirements. Identify training needs outside of core curriculum to promote maximized effectiveness in managing medical costs and improving clinical outcomes. Maintain and monitor the delivery and effectiveness of the training programs, identify solutions to challenges and implement improvements. Assist with the development and evaluation of performance goals and objectives and quality management activities. Develop and facilitate new hire orientation for the clinical staff and ensure transition of training into daily work activities related to clinical practice, patient safety and evidence-based practice Performs quality audits and facilitates inter-rater reliability assessments to ensure standardization and consistency with clinical decisions Support and provide education with process improvement programs and technical applications. Develop programs to support educational needs as determined by management. Present status reports on all cases to the manager/supervisor and, when indicated, to the medical director. Maintain all standards in consideration of state, federal, BCBSAZ, URAC, and other accreditation requirements. Maintain complete and accurate records per department policy. Participate in continuing education and current development in the field of medicine and managed care. Facilitate interdisciplinary care round/discussions under the direction of the VP, Clinical Benefit Manager and/or delegate. 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 Work Experience
5 years of direct clinical care experience in a healthcare setting
2 years work experience in a managed care setting
4 years of clinical training or clinical education experience, preferably in managed care. Required Education
Associate Degree or in Nursing Required Licenses
Active, current, and unrestricted license to practice in the State of Arizona (a state in the United States) as a Registered Nurse (RN). Required Certifications
Preferred Work Experience
5 years of experience in clinical education, training and instructional design
1 year of experience working with Milliman Care Guidelines (MCG), InterQual and/or other clinical criteria/guidelines Preferred Education
Bachelor's Degree in Nursing or Master’s Degree in Nursing Preferred Certifications
Active and current certifications in the following certifications: Certified Case Manager (CCM) or Utilization Management Certification
Required Job Skills Strong written and verbal communications. Excellent organizational skills and strong attention to detail
Possess proficient computer and technological skills especially Word, Excel, Powerpoint, SharePoint, Lync/Webinar and Internet
Ability to gather, analyze data and prepare informative and accurate reports.
Ability to understand the workflow of multiple components of the company and to assist in the creation and implementation of integrated policies, procedures, workplans and creative solutions. Required Professional Competencies
Ability to develop, organize, motivate, coordinate and collaborate effectively with stakeholders from multiple business areas across the organization Ability to successfully function in an environment characterized by risk taking, rapidly changing market conditions, strong competition and restructuring. Strong understanding of the costs/quality challenges of today’s health care environment. Knowledge of health and/or patient education and behavior change techniques Organizational skills to analyze, interpret data, synthesize, evaluate and explain educational concepts, practices and methodologies to staff and transfer data to and from written and verbal medium. Ability to maintain confidentiality and privacy Advanced knowledge of Adult Learning Theory principles and demonstrated ability to facilitate training that resonates with all learning styles Practice interpersonal and active listening skills to achieve customer satisfaction Demonstrated organizational skills with the ability to priortize 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 skilll Required Leadership Experience and Competencies Desire and capability to drive toward and achieve high standard of quality and results. Mindset geared toward the creation, execution and continuous improvement of clinical benefit management department and programs. Intellectual curiosity and ability to view old problems/issues with a fresh perspective. Ability to perform job role duties independently. Ability to professionally represent BCBSAZ in the community