Quality Assurance Consultant

Arizona Department of Administration•Phoenix, AZ

7d•Hybrid

About The Position

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, on-site investigations at least 20% of your time, 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

Knowledge of: • State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, and LTC Supports and Services • Current standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care/services • Data management and utilization review regulations, rules and processes • AHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules • Medical/nursing practice, medical case management protocols, utilization review protocols as related to the acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, and behavioral/mental health • Case management development, implementation, and ongoing review
Skill in: • Acute nursing and clinical processes including assessment, planning, intervention, and evaluation • Clinical assessment skill • Techniques to select a particular approach to analyze develop or implement a policy, project management methodologies, and Behavioral Health delivery system • Problem-solving techniques, evaluation, and initiation of appropriate action • Excellent communication, verbal and written • Organizational skills for setting priorities, workload, and record-keeping • Strong interpersonal skills in working with agency management, and people of diverse cultures and socioeconomic backgrounds • Project management to meet goals and deadlines • Research and analytical skills • Documentation and reporting of data and trends
Ability to: • Strong ability to collaborate with others for a mutually beneficial outcome • Interpret clinical information and assess implications for treatment • Read, interpret and apply complex rules and regulations • Independent decision making, yet knowing when to elevate an issue or concern • Assess variables which impact health and functioning • Make effective decisions in a high volume, fast paced environment • Write comprehensive reports
Minimum: 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.
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 pertaining to quality management processes, tracking, and trending 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.
Contributes clinical knowledge to assist in the resolution of quality of care concerns, clinical reviews and Operational Reviews. Completes an independent review of data management 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.
Conduct on-site investigations regarding possible health and safety concerns, immediate jeopardy situations, and other situations supporting AHCCCS initiatives and ventures. On-site visits may also occur outside of normal business hours and weekends for immediate and urgent situations.
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.
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.
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.

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. Learn more about the Paid Parental Leave pilot program here.
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
Lifetime Pension Benefit Program • Administered through the Arizona State Retirement System (ASRS) • Defined benefit plan that provides for life-long income upon retirement. • Required participation for Long-Term Disability (LTD) and ASRS Retirement plan. • Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).
Deferred Retirement Compensation Program • Voluntary participation. • Program administered through Nationwide. • Tax-deferred retirement investments through payroll deductions.