ALTCS PA/UR Consultant

Arizona Department of Administration • Phoenix, AZ

6d • Remote

About The Position

This position will review Prior Authorization (PA) requests and determine
medical necessity for Physical, and/or Behavioral Health Services (including
Children's Rehabilitative Services [CRS]), for the Division of Developmental
Disabilities (DDD) Tribal Health Plan (THP) population and approve or deny PA
requests. This position also provides support to Arizona Department of Economic
Security/ Division of Developmental Disabilities (DES/DDD) THP staff, Fee For
Service (FFS) providers, tribal stakeholders, and AHCCCS staff while following
guidelines, standard of care, regulations, policies, and procedures governing
the provision of covered services.

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.

Requirements

• Principles of medical and/or behavioral management and assessment
• Medical/nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, behavioral/mental health
• Current costs, appropriateness and utilization of medical supplies and equipment
• Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services
• Managed care processes
• Acute nursing processes including assessment, planning, intervention and evaluation
• ICD-9/10 Diagnosis Coding; DSM-IV/V; CPT procedure coding
• Medical technology computer data retrieval and input
• Interrelations of governmental agencies
• 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)
• Organizational skills for setting priorities; workload, record keeping, and prioritization of multiple tasks
• Interpretation of rules, laws and agency policy pertaining to the AHCCCS program
• Good written and verbal communication skills
• Computer skills
• Utilization Review and Medical Claims Review skills
• Producing work products with limited supervision
• Effectively collaborating with people in positions of all levels
• Research and analysis
• Team player and can work independently
• Interpret and apply medical and claims policy
• Evaluate medical documentation for emergency criteria, medical necessity, and correct CPT coding
• Document rationale for UR/CPT coding decisions
• Negotiate competitive rates to maximize available funding for members' care
• Determine appropriate hospital levels of care and lengths of stay
• Respond to inquiries and grievances and answer utilization review questions
• Independent decision making
• Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and 3 years of relevant healthcare experience.
• May require a valid Arizona Driver License for travel-related duties.
• 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.)
• All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Nice To Haves

• Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served.

Responsibilities

• Review clinical documentation, performs prospective, concurrent and retrospective reviews for medical necessity, appropriateness for admission, length of stay, level of care, quality of care, coordination of care based on State and Federal regulations, policies, and procedures governing the provision of covered services.
• Collaborates with providers, Tribes, DES/DDD, and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, work flow, complex member needs, and other issues.
• Provides education and technical assistance to FFS Providers, Tribal Staff, and AZDES/DDD as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies and procedures.
• Evaluates, recommends action, negotiates rates, and provides on-going monitoring or program policy compliance and reporting of data related to specialty services such as Specialty DME, and Exception NF Rates.
• Participates in process improvement and other special projects, work groups and committees to improve the efficiency of care coordination, utilization management and other unit functions.
• Tracks and/or performs reviews for compliance related to utilization management processes and Federal and State rules and regulations related to the AHCCCS THP populations.
• Devises and submits system generated reports, extracts, and analyses for unit, division, and management. Maintains documentation files.

Benefits

• 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.
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees