Care Management Nursing Consultant

Arizona Department of Administration • Phoenix, AZ

1d • 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. This position will work independently applying clinical knowledge, judgment, and expertise to assess, coordinate, and monitor service delivery. This position will complete comprehensive assessments of available resources on service providers and individual members; review case material to ensure compliance with State and Federal regulations and policies; and provide timely resolution of multiple cases assigned. This position will also be responsible for identifying systemic issues for AHCCCS to address. This position will be hybrid with some in-office meetings and on-site investigations and reviews as needed. Occasionally, this position may also participate as needed in urgent on-site investigations and reviews outside of normal business hours and weekends. 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

• 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

• Monitor compliance with State and Federal regulations, tracking, and trending case management data to include escalation of and action taken by case management team in response to COOP initiation, quality of care concerns and/or health and safety/immediate jeopardy concerns.
• Receive, research, document, and resolve quality of care and/or health and safety issues utilizing standardized processes.
• Track, trend, and monitor the status of cases to ensure accurate and timely completion and appropriate referrals using a centralized case management tracking database.
• Ensure research and resolution of issues or concerns promptly as assigned and identify systemic issues for AHCCCS to address.
• Ensure quality of care to AHCCCS members, including ensuring member dignity and respect, focused on their unique special health care needs, timely correspondence, and resolution of the quality of care concern.
• Use independent judgment regarding data to research, status level, interventions, and appropriate resolution.
• Contributes clinical knowledge to assist in the resolution of quality of care concerns, clinical reviews and Operational Reviews.
• Completes an independent review of data and other deliverables, technical assistance, and focused studies/reviews, including the behavioral health delivery system, to ensure compliance with contractual and policy requirements for all lines of business.
• Follow-up on written reports, action plans, provider education, and related actions as appropriate.
• Provide education and technical assistance to internal and external stakeholders as appropriate, regarding covered services, and contractual or policy requirements, accurately and consistently to improve compliance with AHCCCS requirements and improve quality of care and service to AHCCCS members.
• Develop improved processes and procedures to improve the efficiency of the unit.
• Lead special projects and reviews to ensure completion within the designated timelines.
• Provide ongoing updates to Management.
• Develop metrics for population-specific outcome objectives.
• Tracking, evaluation, analysis, and revision of metrics as needed based on the ongoing analysis of member data.
• Conduct on-site investigations regarding possible health and safety concerns, immediate jeopardy situations, and other situations supporting AHCCCS initiatives and ventures. Occasionally, and may be required outside of normal business hours and weekends.

Benefits

• 10 paid holidays per year
• Paid Vacation and Sick time off (13 and 12 days per year respectively)
• 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