Address: 150 North 18th Avenue Phoenix, Arizona 85007

All AHCCCS Employees must reside within the state of Arizona. 

Salary: $71,032

FLSA Status: Exempt

Grade: 22

Position will remain open until filled.

Under the general direction of the Medical Management (MM) Manager and Supervisor, this position will monitor and evaluate Medical Management programs for the AHCCCS Complete Care Contractors, Arizona Long Term Care System and RBHA Contractors. Provide oversight of the MM process at the Contractor level. Participate in the Operational Review and develop, update, review and interpret policy pertaining to MM.

Major duties and responsibilities include but are not limited to:
• Prepares for and participates in audits to include the review of pre-audit documents and polices, on site audit, formal written documentation of findings and monitoring the corrective Action Plans as applicable.
• Provides oversight of transplant reinsurance for each Contractor including sending letters of approval and maintaining the reinsurance case in PMMIS. Provide assistance to DFSM for approval for Tribal Fee-For-Service members. Document in transplant database, create cases in PMMIS & send letter of approval to the transplant facilities. In the case of potential denial of services, the MM specialist will be present the clinical information to the Medical Director (MD). If MD denies the request, an appropriate Notice of Action must be issued to the member & notify requesting provider.
• Reviewing catastrophic cases to ensure that AHCCCS clinical criteria for reinsurance are met. Creating reinsurance cases and providing written approval letters to Contractor.
• Review of all MM contractual deliverables including the annual Medical Management/Utilization Management (MM/UM) Plan, work plan and Evaluation for each Contractor along the written communication outlining any deficiencies that need to be corrected.
• Review, research, develop issue paper on assigned topic, and present to the AHCCCS Technology and Services Committee.
• Provides technical assistance to the Contractors as needed relating the MM policies, transplant activities or catastrophic reinsurance. Address member concerns and document activity within database.
• Attends Quarterly MM meetings and other ad hoc meetings as necessary. Participates in the Transplant Coordinators Work Group and acts as liaison between AHCCCS Contractors and transplant facilities.
• Assists in the review and revision of MM policies as needed.

Knowledge:
• Nursing principals and practices
• Principals and practices of medical management
• Federal regulations, State statute, rule, policy and procedure governing the AHCCCS program
• AHCCCS contractual agreements with Contractors
• Basic knowledge of computers
• Working knowledge of Word and Excel
• Current medical knowledge including evidence based medicine standards

Skills:
• Analytical skills to interpret utilization management data
• Excellent oral and written communication skills
• Effective interpersonal skills
• Critical thinking skills

Abilities:
• Multi-task in a fast paced environment, re-prioritizing as needed
• Develop implement and review case management and utilization review systems
• Offer technical assistance to Acute, LTC, Other State agencies and/or Tribal Contractors
• Work independently and collaboratively with a team
• Communicate with all levels of professional, corporate and agency officers and members

Arizona Driver's License.

Minimum:
• A licensed Registered Nurse, Physician's Assistant or Nurse's Practitioner is required and three (3) years of relevant clinical experience. Experience in the administration, direction, or implementation of the Medicaid program is not considered the equivalent of a professional training in a field of medical care.

Preferred:
• Experience working as an AHCCCS Contractor.

• Experience working independently and applying utilization management skills.

• 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.) AND have an acceptable driving record for the last 39 months including no DUI, suspension or revocations and less than 8 points on your license. If an Out of State Driver License was held within the last 39 months, a copy of your MVR (Motor Vehicle Record) is required prior to driving for State Business. Employees may be required to use their own transportation as well as maintaining valid motor vehicle insurance and current Arizona vehicle registration; however, mileage will be reimbursed.

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.