ALTCS PA/UR Nursing Consultant

Arizona Department of Administration•Phoenix, AZ

1d•$71,032•Hybrid

About The Position

The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid Agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry. 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.

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
Ability to interpret and apply medical and claims policy
Ability to evaluate medical documentation for emergency criteria, medical necessity, and correct CPT coding
Ability to document rationale for UR/CPT coding decisions
Ability to negotiate competitive rates to maximize available funding for members' care
Ability to determine appropriate hospital levels of care and lengths of stay
Ability to 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)
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.
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
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, administered through Nationwide, tax-deferred retirement investments through payroll deductions).