Public Health Nursing Consultant

Arizona Department of Administration • Phoenix, AZ

1d • $71,032 - $73,032

About The Position

Under the general direction of the Medical Management (MM) Manager and
Supervisor, this position will monitor and evaluate Medical Management programs
for the AHCCCS Complete Care Contractors, Arizona Long Term Care System and RBHA
Contractors. Provide oversight of the MM process at the Contractor level.
Participate in the Operational Review and develop, update, review and interpret
policy pertaining to MM.

Requirements

• Must maintain a current Arizona medical license (RN or higher), and 3 years of relevant healthcare experience.
• Nursing principals and practices
• Principals and practices of medical management
• Federal regulations, State statute, rule, policy and procedure governing the AHCCCS program
• AHCCCS contractual agreements with Contractors
• Basic knowledge of computers
• Working knowledge of Word and Excel
• Current medical knowledge including evidence based medicine standards
• Analytical skills to interpret utilization management data
• Excellent oral and written communication skills
• Effective interpersonal skills
• Critical thinking skills
• Multi-task in a fast paced environment, re-prioritizing as needed
• Develop implement and review case management and utilization review systems
• Offer technical assistance to Acute, LTC, Other State agencies and/or Tribal Contractors
• Work independently and collaboratively with a team
• Communicate with all levels of professional, corporate and agency officers and members

Nice To Haves

• Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served.

Responsibilities

• Prepares for and participates in audits to include the review of pre-audit documents and polices, on site audit, formal written documentation of findings and monitoring the corrective Action Plans as applicable.
• Provides oversight of transplant reinsurance for each Contractor including sending letters of approval and maintaining the reinsurance case in PMMIS. Provide assistance to DFSM for approval for Tribal Fee-For-Service members. Document in transplant database, create cases in PMMIS & send letter of approval to the transplant facilities. In the case of potential denial of services, the MM specialist will be present the clinical information to the Medical Director (MD). If MD denies the request, an appropriate Notice of Action must be issued to the member & notify requesting provider.
• Reviewing catastrophic cases to ensure that AHCCCS clinical criteria for reinsurance are met. Creating reinsurance cases and providing written approval letters to Contractor.
• Review of all MM contractual deliverables including the annual Medical Management/Utilization Management (MM/UM) Plan, work plan and Evaluation for each Contractor along the written communication outlining any deficiencies that need to be corrected.
• Review, research, develop issue paper on assigned topic, and present to the AHCCCS Technology and Services Committee.
• Provides technical assistance to the Contractors as needed relating the MM policies, transplant activities or catastrophic reinsurance. Address member concerns and document activity within database.
• Attends Quarterly MM meetings and other ad hoc meetings as necessary. Participates in the Transplant Coordinators Work Group and acts as liaison between AHCCCS Contractors and transplant facilities.
• Assists in the review and revision of MM policies as needed.

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: No Education Listed
• Number of Employees: 501-1,000 employees