Informatics & Prepayment Review Health Consultant

Arizona Department of Administration • Phoenix, AZ

5d • $71,032 • Remote

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.

Requirements

• State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, Behavioral Health, LTC and Tribal and Children’s Rehabilitative Services
• Clinical experience in various medical/ behavioral health settings including understanding of the technology and information
• Current standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care services
• Data analysis, data management and utilization review regulations, rules and processes and interpretation
• AHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules
• Structure and operation of the Arizona behavioral health system
• Advanced skills in Microsoft Office (SharePoint, Excel, Access) and Google suite
• Problem-solving techniques, evaluation, and initiation of appropriate action
• Excellent communication, verbal and written skills
• Organizational skills for setting priorities, workload, and record-keeping
• Strong interpersonal skills in working with agency management, cross divisional, and interdisciplinary groups including people of diverse cultures and socioeconomic backgrounds
• Project management skills including system implementation, process improvement and ability to meet goals and deadlines
• Research and analytical skills
• Documentation and reporting of data and trends with clinical significance
• Behavioral Health processes including assessment, treatment planning, intervention, and evaluation
• Acute nursing and clinical processes including assessment, planning, intervention, and evaluation
• Explain complex data in a succinct and clear manner that people can understand
• Understand complex data reports
• Read and interpret a spreadsheet
• Write comprehensive reports such as data driven decision making and quality improvement to enhance outcomes
• Read, interpret and apply complex rules and regulations
• Adapt to new technology and programs assisting with data analysis and inference/ applicability to other areas
• 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.
• Experience in outpatient behavioral health services.
• Preferred skills in power BI.

Responsibilities

• Perform prepayment review of behavioral health documents submitted in support of behavioral health claims. Including responses to disputes of behavioral health claims.
• Identify trends, issues, outliers which may need to be addressed by DFSM and/or other leaders. Succinctly and clearly summarizes data issues and trends in writing and verbally. Makes direct referrals to OIG, QM and PPR teams as appropriate based on findings.
• Responsible for creating reports and presentations which synthesize information and explain the clinical significance as well as the rationale of findings and recommendations.
• Serve as a DFSM Informatics SME, overseeing all the data for the division, including ODA analytics reports submitted for review to the division. Develop reports in Cognos which can be easily run ad hoc by staff. Including providing technical assistance and training to staff in use of Cognos. Set up special handling's in PMMIS and Alivia.
• Responsible for data analysis project management; creating and maintaining reports & meetings as necessary. Follow-up on written reports, action plans, escalations, education, and other actions as appropriate. Focus on continuous process improvement related to Data and Reporting processes leading projects as needed.
• Provides education, technical assistance to internal and external stakeholders, and participates in various cross agency meetings serving as subject matter expert of the data for the division. Share reports and updates regularly with leadership based on data analysis.

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: Entry Level
• Education Level: Associate degree