AHCCCS

Address: 801 E. Jefferson Street, Phoenix, AZ 85034

This position has the potential to work from a Virtual Office (VO) setting or may Telecommute based on the needs of the unit and at the discretion of leadership.

Salary: $71,032 

Grade: 22

Closing Date: Open until filled

The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review for the Fee for Service population. The position determines medical necessity based on standards of care, rules, regulations, policies and procedures governing the provision of covered services. This position will primarily work from home with some in-office meetings and on-site duties being required.

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:
• Collaborates with providers, Tribal and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs, and other issues
• Evaluates, recommends action, negotiates rates, and provides ongoing monitoring for program policy compliance and reporting of data related to specialty services such as Specialty DME, Exception NF Rates, and Over Institutional Cost services.
• Confers with Utilization Review Coordinators from the Peer Review Organization regarding concurrent review of length of stay and appropriateness of services.
• Provides education and technical assistance to FFS Providers and Tribal staff as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies, and procedures.
• Tracks and/or performs focused reviews for compliance related to utilization management processes and Federal and State Rules and Regulations related to the AHCCCS FFS populations. Maintain documentation files.
• Devises and submits system generated reports, extracts, and analyses for unit and division and management.
• Participates in process improvement and other special projects, work groups, and committees to improve the efficiency of care coordination, utilization management, and other functions in the Clinical Administration unit.

Knowledge:
• Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services
• Principles of medical and/or behavioral management and assessment
• Current standards of medical/behavioral practice and delivery of acute/non-acute medical/behavioral care
• Current costs, appropriateness and utilization of medical supplies and equipment
• Principles of utilization review
• Alternative levels of care.
• ICD-9/10 Diagnosis Coding; DSM-IV/V; CPT procedure coding
• Medical technology computer data retrieval and input
• AHCCCS, ALTCS, Medicaid and Medicare Federal Regulations. State Statute and Rule and policies applicable to AHCCCS programs, policies and procedures
• Code of Federal Regulation (42 CFR)
• Medical and psycho- social needs of ALTCS members, cultural, environmental, and community influences on behavior of ALTCS members
• AHCCCS and ALTCS program design and implementation, including case management functions and responsibilities, provider network, and funding source
• Familiarity with American Indian Tribes/ programs and policy relative to IGA's and other related policies

Skills:
• Problem solving-identification; evaluation and initiation of appropriate action; nursing assessment
• Public relations skills, interacting with statewide providers of healthcare services, public organizations, and social agencies
• Organizational skills for setting priorities; workload, and record keeping
• Intermediate computer skills to access and input member information
• Analytical ability to identify and correlate specific patterns, initiate investigations, submit findings and recommendations
• Strong Interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds

Abilities:
• Proficiency in oral and written communication
• Teach and train
• Interpret clinical information and assess implications for treatment
• Negotiate competitive rates to maximize available funding for members' care
• Read, Interpret, and apply complex rules and regulations
• Independent decision making

Arizona Driver's License

Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and three (3) year of relevant experience.

Preferred: Professional experience in the Healthcare Industry - specifically experience in Prior Authorization, Concurrent Review, Retrospective Review, and Utilization Management.

• 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.