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 Workforce Strategy Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, 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, 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 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 at a minimum of once per week. Purpose of the Job Direct, lead and provide professional oversight for medical management activities related to utilization management, case management, disease management, and quality management activities. Support collaborative relationships with physicians and hospitals to achieve mutually acceptable business goals and to ensure that medical policies, procedures and the activities/actions of the division on behalf of the corporation are consistent with the standards of good medical practice in the community. Impact organizational performance by supporting and advising the organization on utilization management and related medical management initiatives. Collaborate with the business, clinical, and operations teams to eliminate barriers and improve outcomes to drive value and quality of care. Work collaboratively with Member Management Team (MMT) to help improve member engagement and encourage appropriate healthcare utilization by delivering timely clinical interventions that improve outcomes. Use data and information to develop comprehensive medical management strategies that improve quality of care, lower costs, and align with the organization’s day‑to‑day priorities. Encourage continuous improvement by becoming an industry expert as a source of knowledge and best practice guidance for the organization. Serve as a clinical SME for medical management working groups and committees and provide guidance and expertise on medical management from a clinical perspective. Act as clinical chief of staff, contributing to the development of care plans for patients, influencing the patient experience and ensuring the best outcomes are achieved. Establish and maintain best practices for medical Management including but not limited to case management, quality improvement (QI), medication, policies, and procedures; review noncompliance and providing successful email and communication with involved parties. Work with external partners to design and negotiate contracts meeting the needs of our members, high-quality patient care, and improve engagement and cost savings. Create training materials and modules to support learning and development of the organization and workforce. Implement new technologies and programs, including measuring outcomes, monitoring progress, troubleshooting and analytics to achieve improved performance on key metrics. Qualifications Required Qualifications 3 years of experience in a clinical setting 1 year of experience in a physician leadership role, including quality review, utilization review and other managed care functions Medical Degree Active, current, and unrestricted license to practice medicine in the State of Arizona Board Certification Preferred Qualifications 3 years of experience in a primary care field N/A N/A N/A Essential Job Functions and Responsibilities Provide direction, support and medical expertise and oversight to areas within the Health Services Division such as utilization management, quality management, case management, medical claims review, and pharmacy management. Specific activities include outcome analysis, HEDIS, dispute resolution, regulatory compliance, care and disease management, concurrent review, pre‑certification, medical claims reconsideration, and retrospective review. Provide consultative services throughout the corporation, including for the Marketing, Sales, Legal, Actuarial, Network Management, Internal Audit, Finance, and Claims Divisions. Communicate with customers regarding their difficult and costly cases, including recommendations and showing the impact of BCBSAZ interventions. Seek to improve department/division efficiency through effective use of information system tools and processes to reduce healthcare costs, increase quality of care and service, and reduce administrative expense. Review, and implement medical policies and other medical decision‑making policies or procedures. Represent BCBSAZ at professional organizations and act as liaison with individual health care professionals and supports collaborative relationships with physicians and hospitals. Provide professional oversight for the various clinical peer committees including, but not limited to, the Clinical Quality Improvement Committee, Credentialing Committee, Medical Directors Committee, and Medical Management Committee. Participate in the appeals and grievance processes to assure timely and accurate responses to members and providers. Conduct, as appropriate, Appeal Peer Review cases in accordance with the required qualifications. Provide written information to members and providers through letters and articles in member and provider newsletters and other publications. Work to ensure productive relationships with all customers, employers, members, and providers to ensure members receive the appropriate health care in the most appropriate setting with the best value in health care. Provide leadership to staff and other professionals through clinical excellence, professional behavior and innovative thinking. Monitor quality performance measures, develop and maintain effective workflows, and seek to maximize system efficiencies. Identify opportunities to achieve administrative efficiencies while maintaining service. Maintain effective working relationships to ensure teamwork in achieving corporate goals. Contribute to departmental and cross‑functional teams to achieve BCBSAZ goals and ensure future success. Coordinate activities between multiple divisions to achieve desired results. Perform all other duties as assigned. Competencies Required Competencies Required Job Skills Strong written and verbal communications. Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones. Intermediate skill in word processing, spreadsheet and database software. Intermediate PC proficiency. Required Professional Competencies Interpersonal skills that allow for harmonious relationships with providers, members and coworkers. Preferred Competencies Preferred Job Skills N/A Preferred Professional 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. #J-18808-Ljbffr