AHCCCS

Address: 150 N. 18th Avenue Phoenix, Arizona 85007

All AHCCCS employees must reside in Arizona.

Salary: $83,600 

Grade: 23

FLSA Status: Exempt

Closing Date: Open until filled

Under the direction of the Utilization Review (UR) Administrator, this position is responsible for the management and oversight of Division of Fee for Service Management (DFSM) Clinical Review Unit (CRU) staff, ensuring the timely and accurate completion of clinical reviews in various clinical units within the DFSM. Oversight includes technological aspects, interaction with providers, resolution of provider issues and unit reporting.

This position may offer the ability to work remotely, within Arizona, based upon the department's business needs and continual meeting of expected performance measures.

The State of Arizona strives for a work culture that affords employees flexibility, autonomy, and trust. Across our many agencies, boards, and commissions, many State employees participate in the State’s Remote Work Program and are able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona unless an exception is properly authorized in advance.

Major duties and responsibilities include but are not limited to:

• Provides direct management of the Clinical Review Unit and manages the nursing staff and non-nursing staff. Participates in Division and Agency Policy Committees. Oversees and directs the technological aspects of the CRU processes and maintains reporting structures and processes.
• Provides oversight and directs team interaction with Fee-for-Service (FFS) Providers and stakeholders, ensures provider issue resolution including grievance and appeals, and provides technical assistance. Works in conjunction with other clinical teams in the DFSM, staff and teams in other AHCCCS divisions, and external partners as required on quality related matters, care coordination needs, policies, procedures, and processes related to health care services.
• Oversight of the team’s participation in special processes (i.e. SMI or SED determination, OHR assistance, seclusion and restraint, out of state placements, etc.) Provides oversight and directs team interactions with FFS Providers, including provider issue resolution and technical assistance.
• Provides backup for the responsibilities held by the CRU nurses as needed.
• Acts as a FFS subject matter expert while assisting in the development of policies and procedures, as required for delivery of covered health care services.

Knowledge of:
• Medical terminology
• CPT and ICD procedural coding
• Industry standards for retrospective utilization review, prior authorization and assignment of levels of care
• Medical billing guidelines
• Broad scope of knowledge of clinical protocols, current medical and nursing practices, and alternative courses of medical treatment and expected outcomes.
• Grievance proceedings and professional expert testimony
• Principles and practices of administration
• Concepts of program planning and design
• Recognize fraudulent billing and questionable medical practices
• State and Federal regulations / guidelines governing the AHCCCS FFS program
• Managed care principles and quality of care improvement processes
• AHCCCS claims processing system and imaging system

Skilled in:
• Teaching and organizational skills
• Medical assessment skills / decision making
• Excellent oral and written communication
• Strong interpersonal and group skills
• Management skills, human relations skills in order to direct staff towards an atmosphere of teamwork
• Develop, implement, and review Medical Review policies within the AHCCCS FFS program
• Plan, organize, and administer a health program
• Resolve problems of non-compliance related to both personnel and programs

Ability to:
• Interpret and administer rules and regulations related to the AHCCCS FFS program
• Conduct effective training and effective meetings
• Manage stressful situations such as being questioned during a judicial proceeding
• Work independently, with a minimal amount of supervision
• Make competent judgments in the absence of higher-level supervision
• Assess the AHCCCS population with a medical emphasis, recognizing medical, environmental and emotional conditions that influence medical conditions
• Effectively evaluate program / unit / personnel performance

Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and four (4) years professional experience related to health programs appropriate to the assignment, which includes program planning or administration; AND Two (2) plus years of managerial experience or (2) plus years as an AHCCCS Health Care Nursing Consultant. A Master's degree in a field appropriate to the assignment may substitute for one year of the required experience.

Preferred Qualifications: Professional experience in the health care industry in review and management of utilization, prior authorization, medical claims. With a certification as a professional CPT coder and/or experience in medical coding/billing. Experience working in the tribal healthcare delivery system.

• Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions.
• Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.)

If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements.

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Among the many benefits of a career with the State of Arizona, there are:
• 10 paid holidays per year
• Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)
• Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child. Learn more about the Paid Parental Leave pilot program here.
• Other Leaves - Bereavement, civic duty, and military.
• A top-ranked retirement program with lifetime pension benefits
• A robust and affordable insurance plan, including medical, dental, life, and disability insurance
• Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)
• RideShare and Public Transit Subsidy
• A variety of learning and career development opportunities

By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.

Learn more about the Paid Parental Leave pilot program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Lifetime Pension Benefit Program
• Administered through the Arizona State Retirement System (ASRS)
• Defined benefit plan that provides for life-long income upon retirement.
• Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.
• Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).

Deferred Retirement Compensation Program
• Voluntary participation.
• Program administered through Nationwide.
• Tax-deferred retirement investments through payroll deductions.

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.
Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.