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PURPOSE OF THE JOB

• Develops, implements and oversees the Medicaid Segment of AZBLUE's Accreditation Plan resulting in successful attainment of Accreditation. Develops and directs accreditation preparation activities and accrediting body reviews.
• Responsible for maintaining and ensuring all policies and procedures are up to date and in compliance with all accrediting and regulatory bodies for the Medicaid Segment to include NCQA, URAC, CMS and AHCCCS.
• Works collaboratively with the broader AZ Blue accreditation and quality teams to support reaccreditation and jointly operated health plans.
• Works collaboratively in a matrixed relationship with compliance and legal to insure all regulatory, compliance and legal requirements are met by the Medicaid Segment.
• Facilities and drives the completion of work requirements of all departments accountable for accreditation deliverables for the Medicaid Segment under the authority of the Medicaid Segments Chief Medical Officer and the entire Medicaid Segment's leadership team.

QUALIFICATIONS

REQUIRED QUALIFICATIONS

1. Required Work Experience

• 10 years of experience in the application of managed care practices
• 10 years of quality and management experience
• 5 years of accreditation experience
• 5 years of Medicare or Medicaid experience

2. Required Education

• Bachelor's degree in a Health Service related field

3. 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).

4. Required Certifications

• N/A

PREFERRED QUALIFICATIONS

1. Preferred Work Experience

• 10 years' experience in Quality Management , continuous quality improvement and outcomes reporting
• 3 years of experience in developing short and long range strategic plans, forecasting, and budgeting
• 5 years of experience in providing leadership to an established, sophisticated medical/health management division of a health insurance organization

2. Preferred Education

• Post-graduate education in Health Care Administration, Public Health and/or M.B.A.

3. Preferred Licenses

• N/A

4. Preferred Certifications

• Certified Specialist in Healthcare Accreditation (CSHA)
• Certified Professional in Healthcare Quality (CPHQ)

ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES

ACCREDITATION

• Develop and implement an Accreditation Program to include organization wide training and preparation for accreditation surveys, and ongoing readiness activities
• Coordinate and oversee regulatory activities to ensure integration and cohesion throughout accredited divisions
• Act as resource to staff and other departments in the area of accreditation and quality improvement
• Coordinate and submit applications, attestations, and required accreditation documents to the accrediting body and CMS
• Coordinate and supervise accreditation reviews and function as the liaison between the organization and the accrediting body
• Develop and train staff on the use of processes and tools to assess compliance with accreditation standards
• Develop and implement an ongoing accreditation readiness assessment program
• Ensure a comprehensive delegation oversight program is in place. Evaluates and modifies oversight program as needed to ensure ongoing business needs and requirements met.
• Participate on internal, external and Association workgroups and teams as needed
• Assist leadership monitoring and analysis of accreditation outcomes to promote meeting goals, objectives, accreditation, and regulatory requirements, and accreditation related quality improvement activities are effective.
• Prepare and deliver Executive Summary reports.
• Maintain Business Continuity Plan for the Quality Department annually.
• Plan, organize and direct staff to optimize the day to day operations of the quality and accreditation department.
• Serve as the subject matter expert to the internal organization for accreditation and clinical quality

LEADERSHIP

• Assume a leadership role in the development of any direct reports and acquisition of new talent by providing challenges and opportunities for awareness and growth
• Maintain effective working relationships to ensure teamwork in achieving corporate goals.
• Foster good communication with staff by setting clear directives, objectives and providing exchange of ideas
• Provide leadership and recommend change management principles to ensure they maximize benefit and alleviate unnecessary disruption.
• Collaborate with Data Science and Analytics to analyze utilization and identify opportunities to offer additional health management services to various customer segments, as well as, trend analysis and development of services for program advancement.

ADMINISTRATIVE

• Manage use of corporate funds including budgeting, financial management, and reporting. Monitor and report on quarterly budget variances. Identify opportunities to achieve administrative efficiencies while maintaining service.
• Establish department goals in accordance with overall BCBSAZ objectives and divisional strategic planning
• Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve the Medicaid Segment and BCBSAZ's future success.
• Ensure the existence of documented department policies and procedures.
• Coordinate activities between multiple divisions to achieve desired results.
• Volunteer within the community to help BCBSAZ give back to community charitable efforts.
• 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. Onsite expectations can change based on the business need.
• Perform all other duties as assigned.

COMPETENCIES

REQUIRED COMPETENCIES

1. Required Job Skills

• Strong organizational skills
• Strong written and verbal communications.
• Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones.
• Strong skill in word processing, spreadsheet and database software.
• Strong PC proficiency.

2. Required Professional Competencies

• Excellent management skills as they relate to clerical and professional staff
• Comprehensive knowledge of Medicaid, Medicare, DSNP, CMS, and AHCCCS program regulations and standard policies and procedures.
• Comprehensive knowledge of Accreditation processes and compliance.
• Interpersonal skills that allow for harmonious relationships with providers, members and coworkers
• Ability to successfully function in an environment characterized by risk taking, rapidly changing market conditions, strong competition and restructuring.
• Proven knowledge of medical care delivery systems, quality management, benefit interpretation, provider relationships, and member services.
• Strong understanding of the costs/quality challenges of today's health care environment.
• Strong understanding of quality metrics and measurement methods.
• Ability to identify key strategic performance measures for success

3. Required Leadership Experience and Competencies

• The capacity, maturity, stature, and communication skills to assume a leadership role in a progressive, growing, and changing organization.
• Ability to work with business unit managers in a partnership setting.
• Ability to work with executive leadership in a professional and collaborative role.

PREFERRED COMPETENCIES

1. Preferred Job Skills

• N/A

2. Preferred Professional Competencies

• N/A

3. Preferred Leadership Experience and Competencies

• N/A