Behavioral Health Prior Authorization Utilization Review Consultant

Arizona Department of Administration•Phoenix, AZ

7d•Hybrid

About The Position

The Behavioral Health Prior Authorization Utilization Review Consultant, within the Division of Fee for Service Management (DFSM), monitors, evaluates, and approves or denies payment for medical and/or behavioral healthcare services for the Fee for Service population through prospective, concurrent, and retrospective review. The position determines medical necessity using standards of care and the rules, regulations, policies, and procedures governing covered services. The role may offer remote work within Arizona, based on departmental business needs and continued performance, and all AHCCCS employees must reside in Arizona. The consultant works with providers, Tribal staff, AHCCCS staff, and Peer Review Organization Utilization Review Coordinators on care coordination, utilization review, prior authorization, coverage criteria, length of stay, appropriateness of services, and member- or provider-specific issues. The role also supports program compliance, reporting, process improvement, and technical assistance. Travel may be required for State business.

Requirements

Maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher).
Three years of relevant healthcare experience.
Proficiency in oral and written communication.
Ability to teach and train, interpret clinical information and assess treatment implications, negotiate competitive rates, read and apply complex rules and regulations, and make independent decisions.
Knowledge of healthcare delivery systems, medical and/or behavioral health management and assessment, current standards of practice, utilization review, alternative levels of care, applicable coding systems, and medical technology data retrieval and input.
Knowledge of AHCCCS, ALTCS, Medicaid, Medicare, applicable Federal and State regulations, statutes, rules, and policies, including 42 CFR.
Knowledge of ALTCS members’ medical and psychosocial needs and of cultural, environmental, and community influences on behavior.
Skill in problem solving, nursing assessment, public relations, organization and record keeping, intermediate computer use, analytical review, and interpersonal communication with people from diverse cultures and socioeconomic backgrounds.
May require a valid Arizona Driver License for travel-related duties.
Successfully pass a fingerprint background check, prior employment verifications, and reference checks.
Complete required driver training if driving on State business, when applicable.
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 the population served.
Familiarity with American Indian Tribes, programs, and policies related to IGAs and related policies.

Responsibilities

Collaborate with providers, Tribal staff, and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs, and related issues.
Evaluate specialty service cases, recommend action, negotiate rates, monitor program policy compliance, and report related data, including for Specialty DME, Exception NF Rates, and Over Institutional Cost services.
Confer with Utilization Review Coordinators from the Peer Review Organization regarding concurrent review of length of stay and appropriateness of services.
Provide education and technical assistance to Fee for Service providers and Tribal staff, including identifying, researching, and resolving member-specific and provider issues to improve compliance with AHCCCS requirements, policies, and procedures.
Track and/or conduct focused reviews of utilization management processes and compliance with applicable Federal and State rules and regulations for AHCCCS Fee for Service populations; maintain documentation files.
Develop and submit system-generated reports, extracts, and analyses for the unit, division, and management.
Participate in process improvement and special projects, work groups, and committees to improve care coordination, utilization management, and other Clinical Administration functions.
Monitor, evaluate, and approve or deny payment for medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review.
Determine medical necessity based on applicable standards of care, rules, regulations, policies, and procedures.

Benefits

10 paid holidays per year.
Paid vacation and sick time: 13 vacation days and 12 sick days per year, beginning on the first day of employment and prorated for part-time employees.
Paid parental leave of up to 12 weeks per year for a newborn or newly placed foster or adopted child.
Bereavement, civic duty, and military leave.
Retirement program with lifetime pension benefits through the Arizona State Retirement System.
Medical, dental, life, and disability insurance.
Eligibility to participate in the Public Service Loan Forgiveness Program, subject to qualifications.
RideShare and public transit subsidy.
Learning and career development opportunities.
Voluntary tax-deferred retirement investments through the Deferred Retirement Compensation Program.