BH PA/UR Consultant

Arizona Department of Administration • Phoenix, AZ

6d • Remote

About The Position

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) and 3 years of relevant healthcare experience.
• May require a valid Arizona Driver License for travel-related duties.

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

What This Job Offers

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