Medical Prior Authorization Consultant

Arizona Department of Administration•Phoenix, AZ

8d•Hybrid

About The Position

The Medical Prior Authorization Consultant works in the Division of Fee for Service Management (DFSM) and monitors, evaluates, and approves or denies payment for medical and/or behavioral health 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, depending on department business needs and continued achievement of performance measures; all AHCCCS employees must reside in Arizona. The consultant collaborates with providers, Tribal staff, AHCCCS staff, and Peer Review Organization Utilization Review Coordinators. The role also provides education and technical assistance, conducts focused compliance reviews, maintains documentation, prepares reports and analyses, and participates in process-improvement projects and committees. 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).
Have at least 3 years of relevant healthcare experience.
May need a valid Arizona Driver License for travel-related duties.
Successfully pass a fingerprint background check, prior employment verifications, and reference checks.
Complete Electronic Employment Eligibility Verification Program (E-Verify).
If driving or using a vehicle is an essential function for State business, meet applicable driver’s license requirements and complete required driver training.
Knowledge of healthcare delivery systems and mechanisms for coordinating and delivering services; medical and/or behavioral health management and assessment; current care standards; utilization review; alternative levels of care; and costs, appropriateness, and use of medical supplies and equipment.
Knowledge of ICD-9/10 diagnosis coding, DSM-IV/V, CPT procedure coding, medical technology data retrieval and input, and applicable AHCCCS, ALTCS, Medicaid, Medicare, State, and Federal requirements, including 42 CFR.
Knowledge of the medical and psychosocial needs of ALTCS members and cultural, environmental, and community influences on their behavior; AHCCCS and ALTCS program design, case management, provider networks, and funding; and American Indian Tribes/programs and related policies.
Skills in problem solving, nursing assessment, public relations, organization and record keeping, intermediate computer use, analysis, and interpersonal communication with people of diverse cultures and socioeconomic backgrounds.
Ability to communicate orally and in writing, teach and train, interpret clinical information and assess treatment implications, negotiate competitive rates, interpret and apply complex rules and regulations, and make independent decisions.

Nice To Haves

Experience in prior authorization, utilization management, claims review, auditing, or managed care.
Knowledge of the population served.

Responsibilities

Collaborate with providers, Tribal staff, and AHCCCS staff on care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs, and related issues.
Evaluate and recommend actions, negotiate rates, monitor program policy compliance, and report data for specialty services, including Specialty DME, Exception NF Rates, and Over Institutional Cost services.
Confer with Peer Review Organization Utilization Review Coordinators regarding concurrent reviews of length of stay and service appropriateness.
Provide education and technical assistance to Fee for Service providers and Tribal staff, including 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.
Prepare and submit system-generated reports, extracts, and analyses for the unit, division, and management.
Participate in process improvement, special projects, work groups, and committees to improve care coordination, utilization management, and other Clinical Administration unit functions.
Determine medical necessity and approve or deny payment for covered medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review.

Benefits

10 paid holidays per year.
Paid vacation and sick time: 13 vacation days and 12 sick days per year, accrued 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.
Remote-work scheduling may support work/life balance, subject to management approval and business needs.