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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in quality of care case management, including compliance with National Medicare and State AHCCCS regulations, while effectively collaborating with healthcare providers and internal teams. Proficient in data management and communication, ensuring member safety and quality standards are upheld.
Highest-signal resume keywords
RN LicenseQuality Management ExperienceKnowledge of AHCCCS RegulationsAnalytical Problem SolvingCommunication Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Quality of Care Case ManagementData ManagementInvestigation CoordinationTriage ReferralsRisk Management IdentificationMonitoring and EvaluationOnsite Health and Safety VisitsDatabase TrackingTraining Program DevelopmentClinical Experience
Soft Skills
CollaborationIndependenceRelationship BuildingVerbal CommunicationWritten Communication
Tools & Technologies
AHCCCS PortalQuality Management Software
Certifications & Qualifications
CPHQ
Industry Keywords
Healthcare ComplianceBehavioral HealthAcute CareOutpatient SettingQuality ImprovementMember SafetyRisk ManagementFWA
About the role
Key responsibilities & impact- Review medical records for quality of care cases
- Use the AHCCCS portal to investigate concerns and ensure compliance
- Support member safety
- Triage new referrals assigned each week
- Collaborate with providers and internal teams
- Occasionally travel to conduct onsite health and safety visits in the Tucson metro area or Casa Grande
- Coordinate investigation of quality of care concerns for Banner University Health Plan members
- Obtain provider responses and prepare acknowledgment and closure correspondence
- Track cases in a database
- Prepare Quality of Care cases and present them to the Medical Director
- Assist with development and implementation of the organization-wide Quality of Care training program
- Communicate monitoring and evaluation results to the QOC Medical Director, QM Director, and QOC Supervisor
- Identify potential risk management, FWA, and Compliance issues for referral
- Facilitate coordination of care while maintaining quality standards and financial responsibility
- Work independently
Requirements
What you’ll need- Physical Health position - Two years of clinical experience in an acute care or outpatient setting
- Behavioral Health position - at least two years of behavioral health experience and strong healthcare knowledge
- Must possess a current, valid RN license in state of practice
- Knowledge of National Medicare and State AHCCCS regulations is required
- Excellent written and verbal communication skills
- Strong analytical, problem solving, concurrent and retrospective data management and computer skills
- Ability to identify variances from protocol
- Ability to work independently to identify, develop, monitor, evaluate, report and perform ongoing, objective, cyclic, and systematic QI indicator data
- Ability to establish good working relationships with BUHP support staff, providers, administrative staff, and internal and external customers
- Experience working in a quality management role in an outpatient or inpatient setting is preferred
- A CPHQ is preferred
- Additional related education and/or experience preferred
- Must reside in the state of Arizona
- Must live in the Tucson metro area or Phoenix metro area