BH PA/UR 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. COME JOIN OUR DYNAMIC AND DEDICATED TEAM. The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review for the Fee for Service population. The position determines medical necessity based on standards of care, rules, 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

Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services
Principles of medical and/or behavioral management and assessment
Current standards of medical/behavioral practice and delivery of acute/non-acute medical/behavioral care
Current costs, appropriateness and utilization of medical supplies and equipment
Principles of utilization review
Alternative levels of care
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)
Medical and psycho- social needs of ALTCS members, cultural, environmental, and community influences on behavior of ALTCS members
AHCCCS and ALTCS program design and implementation, including case management functions and responsibilities, provider network, and funding source
Familiarity with American Indian Tribes/ programs and policy relative to IGA's and other related policies
Problem solving-identification; evaluation and initiation of appropriate action; nursing assessment
Public relations skills, interacting with statewide providers of healthcare services, public organizations, and social agencies
Organizational skills for setting priorities; workload, and record keeping
Intermediate computer skills to access and input member information
Analytical ability to identify and correlate specific patterns, initiate investigations, submit findings and recommendations
Strong Interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds
Proficiency in oral and written communication
Teach and train
Interpret clinical information and assess implications for treatment
Negotiate competitive rates to maximize available funding for members' care
Read, Interpret, and apply complex rules and regulations
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
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

Collaborates with providers, Tribal and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs, and other issues.
Evaluates, recommends action, negotiates rates, and provides ongoing monitoring for program policy compliance and reporting of data related to specialty services such as Specialty DME, Exception NF Rates, and Over Institutional Cost services.
Confers with Utilization Review Coordinators from the Peer Review Organization regarding concurrent review of length of stay and appropriateness of services.
Provides education and technical assistance to FFS Providers and Tribal staff as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies, and procedures.
Tracks and/or performs focused reviews for compliance related to utilization management processes and Federal and State Rules and Regulations related to the AHCCCS FFS populations. Maintain documentation files.
Devises and submits system generated reports, extracts, and analyses for unit and division and management
Participates in process improvement and other special projects, work groups, and committees to improve the efficiency of care coordination, utilization management, and other functions in the Clinical Administration unit.

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.
Program administered through Nationwide.
Tax-deferred retirement investments through payroll deductions.