New

Staff VP, Integrated Clinical Care - Hybrid

Blue Cross Blue Shield of Arizona
United States, Arizona, Phoenix
May 30, 2025
Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy.AZ Blue offersa 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. At AZ Blue, we have a hybrid workforce strategy, called 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 current 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 within 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 within 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 presence 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. Purpose of the job Develop recommendations for innovation to existing clinical services to improve management of medical utilization and costs and using data to design, develop, and support implementation of clinical operations management programs as approved by Clinical Excellence leadership to meet the demographic and epidemiological needs of our members. This includes high-cost claimants, system operations, and other special projects as assigned. Oversee and manage delegated services including the current offshore UM vendor (Accenture) and any future transitions of like-vendors. Provide leadership and oversight for all clinical government program implementations Provide strategic leadership for the integration of CMS Interoperability mandates into clinical operations, ensuring compliance with federal requirements such as the CMS Interoperability and Patient Access Final Rule, while aligning with organizational goals. Drive cross-functional collaboration between clinical, IT, compliance, and other stakeholder teams to implement interoperability solutions that enhance prior authorization workflows, streamline data exchange, and improve member and provider experience. Monitor evolving regulations, accreditation standard, mandates, and industry standards to proactively guide UM policy development, technology investments, and operational readiness, ensuring the organization innovation and compliance. REQUIRED QUALIFICATIONS Required Work Experience 7 years of clinical experience 5 years of management experience 5 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs 5 years of experience in developing short- and long-range strategic plans, forecasting, and budgeting Required Education Bachelor of Arts or Bachelor of Science degree in a healthcare-related field 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 N/A PREFERRED QUALIFICATIONS Preferred Work Experience 10 years of management experience 10 years of clinical experience in a primary care field 10 years of managed care, health services, health outcomes, or disease management experience, specifically in developing and implementing clinical programs 5 years of experience in developing short- and long-range strategic plans, forecasting, and budgeting Preferred Education Master's degree in healthcare administration, business administration or related field Preferred Licenses N/A Preferred Certifications N/A ESSENTIAL job functions AND RESPONSIBILITIES Assume accountability for current in-house management and offshore delegated arrangements, including implementation of all Commercial and Medicare components, training and auditing, monitoring production and ensuring compliance with Federal, State and URAC requirements. Work with Vice President of Clinical Operations and clinical leadership on any program that is required to advance comprehensive medical care. Consult and provide recommendations for data-informed improvement strategies and management support for health management and population management programs that improve health outcomes, reduce hospital re-admissions, improve patient safety and reduce medical errors, as well as support applicable health plan accreditation standards and HEDIS measures. Provide consultation, leadership, administrative and management support, and strategic planning guidance to medical management leadership, utilizing the principles of continuous process improvement to impact efficiency, effectiveness and outcomes to inform recommendations. Develop and support the initiatives to improve the health, safety and welfare of the BCBSAZ members and the overall population health as promoted under Commercial, Individual, and all government programs Identify strategic directions/options for medical management and wellness related systems and propose options, including budget forecasts, system roadmaps and functionality. Promote plan-wide understanding, communication, and coordination of population health management services Manage use of corporate funds including budgeting, financial management, and reporting. Identify opportunities to achieve administrative efficiencies while maintaining service. 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 and improved cost of care. Function as a SME and Company representative for clinical/medical management innovation and present programs to clients and/or other external agencies both in-person and written. Manage responses to Requests for Proposal (RFP) and Requests for Information (RFI). Assist with the development and integration of new products. Support continuous improvement in coordinating and assisting in development of enhancements to existing systems or creations of new systems to improve efficiencies to processing, monitoring quality performance measures, developing and maintaining effective workflows, and seeking to maximize system efficiencies, and identifying and analyzing appeal and grievance patterns to identify opportunities for policy and benefit changes. Function as SME for clinical / medical management innovation and present programs to clients and/or other external agencies both in-person and written. Development and oversight of special affordability projects program and operations Participate in strategic planning activities and contribute to departmental and cross-functional teams to achieve BCBSAZ goals. Support BCBSAZ's Core Value of maintaining a heritage of service, by volunteering with, serving on, and/or supporting multiple Boards of Directors within the community. Maintain effective working relationships to ensure teamwork in achieving corporate goals. Coordinate activities between multiple divisions to achieve desired results. 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 needed to meet business requirements. Perform all other duties as assigned. REQUIRED COMPETENCIES Required Job Skills Strong written and verbal communications. Leadership capabilities with proven success Critical thinking skills Intermediate PC proficiency. Intermediate skill in use of office equipment, including copiers, fax machines, scanner and telephones. Intermediate skill in word processing, spreadsheet, and database software. Required Professional Competencies Management skills in an operationally changing environment, with drive for results based on planned objectives. Strong customer service skills. Ability to influence business leaders and educate providers. Advanced analytical and diagnostic skills dealing with issues that are often novel and not readily defined, lack known precedent or appear contradictory. Interpersonal skills that allow for harmonious relationships with providers, members and coworkers. Recognize strategic opportunities and use data to make timely and sound decisions. Flexibility and willingness to adjust to shifting demands/priorities. Ability and experience to assimilate multiple functions, services, projects and systems while maintaining existing systems and programs. Expert knowledge of medical benefits management, quality initiatives, utilization review, managed care, contracting, negotiation and relationship building. Conceptual and in-depth knowledge of the healthcare industry, including reform, competition, ancillary provider trends, and reimbursement models. Strong ability to deal with abstract and concrete variables, apply principles of logical or scientific thinking to define problems, collect data, establish facts, and draw valid conclusions. Strong knowledge of accreditation and accrediting bodies, including NCQA, and/or URAC. Management skills in an operationally changing environment, with drive for results and success based on planned objectives. Strong customer service skills. Interpersonal skills that allow for harmonious relationships with providers, members and coworkers. Recognize strategic opportunities and use data to make timely and sound decisions. Flexibility and willingness to adjust to shifting demands/priorities. Ability and experience to assimilate multiple new functions, services, projects and systems while maintaining existing systems and programs. Excellent management skills as they relate to clerical and professional staff 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. Comprehensive knowledge URAC, medical policy issues, and utilization management. Strong understanding of the costs/quality challenges of today's health care environment. Strong familiarity with the competition, market environment, healthcare economics, medical practices, managed care issues and provider/managed care systems and structures. Proficiency in health economics analysis and understanding of statistics and health services research Ability to identify key strategic performance measures for success Required Leadership Experience and Competencies High standard of performance while pursuing aggressive goals The capacity, maturity, stature, and communication skills to assume a leadership role in a progressive, growing and changing organization Principled leadership and sound business ethics 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. PREFERRED COMPETENCIES Preferred Job Skills N/A Preferred Professional Competencies N/A Preferred Leadership Experience and 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. Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.