Market Conduct and Consumer Services Division

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.

100 North 15th Avenue
Phoenix, AZ 85007

Salary: $50,000 - $53,500 

Grade: 20

Closing Date: 12/12/2025

The Department (DIFI) is required to administer the health care appeals laws. The laws allow members to request review of denied services or claims as not medically necessary or not covered in the health insurance policy. DIFI makes the determination for policy coverage disputes, while cases involving medical-necessity are sent by DIFI to independent review organizations.

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.

• Process enrollee and provider requests for health care appeals including making determinations on coverage cases; selecting independent reviewers and referring medical-necessity cases for external review; researching statutes and medical and insurance reference materials; obtaining relevant information from insurers, providers and enrollees; tracking and responding to case deadlines; coordinate with agency accounting staff to invoice health insurers for HCA cases requiring external review.

• Perform document and portal management activities to ensure consistency and accuracy of reports. Collect, track and compile data and prepare reports. Assist with preparation of content and maintenance of health care appeals and surprise out of network billing web pages.

• Review enrollee requests for SOON billing arbitration; obtain relevant information from insurers, providers and enrollees, and/or their representatives; determine eligibility for the arbitration process; arrange the informal settlement teleconference; assign arbitrator(s) after verifying absence of conflict; monitor cases for compliance with statutory timelines; refer/educate as appropriate to federal No Surprises Act resources.

• Assist with preparation and editing of operational and action plans, policies, procedures, systems and forms; develop informational resources regarding HCA- and SOONBDR-related issues; coordinate with other divisions to provide technical advice on health care and surprise billing issues; serve as an informed source on all technical matters related to appeals and surprise billing disputes.

• Participate in developing requests for proposal to procure independent medical review organizations; participate in developing any necessary amendments to current IRO contracts; participate in providing quality or utilization data to State Procurement Office in furtherance of state IRO contracts.

• Respond to calls, inquiries and emails about the health care appeals and surprise out of network dispute resolution process. Create form letters and email templates and edit as appropriate to communicate with enrollees, insurers and providers.

Knowledge:
• Arizona health insurance laws, rules and policies, including expertise in the standards for surprise out-of-network billing arbitration and health care appeals.
• General principles of statutory construction.
• Arizona health insurance market, industry practices, medical terminology, types of health conditions, types of medical treatment, types of durable medical equipment, types of medicines, and insurance company operations.
• Federal laws, regulations, and programs and the administration of those programs that pertain to and/or effect the business and transaction of health insurance.
• Policy, processes, procedures, systems, forms and instructions, and other resources for performing job responsibilities.
• Protocols for contacting and dealing with insurance company, provider and billing staff and representatives.

Skills:
• Time-management, project organization and problem-solving.
• Time-management, project organization and problem-solving.
• Regulatory analysis.
• Developing and maintaining effective, professional interpersonal working relationships.
• Reading and interpreting state and federal laws and regulations and insurance contract provisions.
• Communicating clearly and effectively both verbally and in writing.
• Employing discretion and diplomacy in dealing with outside parties.
• Providing superior customer service.
• Using word processing, spreadsheets, Google Mail, Google Team Drive, Google Docs, PDF and comparable programs.

Ability:
• Analyze complex/conflicting data, documents, insurance contract language, draw valid conclusions and adopt and implement an effective course of action.
• Quickly grasp complex subject matter, prioritize assignments and to work autonomously.
• Exercise good judgment and make appropriate decisions.
• Interpret and explain complicated information to others.
• Establish and maintain effective and professional working relationships with stakeholders, insurers, health care providers, coworkers and consumers.
• Communicate diplomatically, clearly and effectively in writing and verbally.
• Plan, organize and coordinate activities with others.
• Adapt to new and changing circumstances.

• A minimum of 2 years of work experience in insurance in a customer-service capacity.

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

The State of Arizona offers a comprehensive benefits package to include:

• Optional employee benefits include short-term disability insurance, deferred compensation plans, and supplemental life insurance
• Life insurance and long-term disability insurance
• Vacation plus 10 paid holidays per year
• Health and dental insurance
• Retirement plan
• Sick leave
• Paid Parental leave

Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.

For a complete list of benefits provided by The State of Arizona, please visit our benefits page.

• Positions in this classification participate in the Arizona State Retirement System (ASRS)
• Please note that enrollment eligibility will become effective after 27 weeks of employment

If you have any questions please feel free to contact Debbie Muhlestein @ debbie.muhlestein@difi.az.gov.