Quality Management Nursing Consultant

Arizona Department of Administration • Phoenix, AZ

23h • Hybrid

About The Position

The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid Agency, is seeking a Quality Management Nursing Consultant. This position will work independently, applying clinical knowledge, judgment, and expertise to assess, coordinate, and monitor service delivery. Responsibilities include completing comprehensive assessments of service providers and individual members, reviewing case material for compliance with State and Federal regulations, and resolving assigned cases. The role also involves identifying systemic issues for AHCCCS to address. This is a hybrid position requiring some in-office meetings, at least 20% on-site investigations, and reviews as needed. Occasional participation in urgent on-site investigations and reviews outside of normal business hours and weekends may be required. The State of Arizona promotes a work culture of flexibility, autonomy, and trust, with opportunities for remote work within Arizona.

Requirements

• Maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher)
• 3 years of relevant healthcare experience
• Knowledge of State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, and LTC Supports and Services
• Knowledge of Current standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care/services
• Knowledge of Data management and utilization review regulations, rules and processes
• Knowledge of AHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules
• Knowledge of 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
• Knowledge of Case management development, implementation, and ongoing review
• Skill in Acute nursing and clinical processes including assessment, planning, intervention, and evaluation
• Skill in Clinical assessment
• Skill in Techniques to select a particular approach to analyze develop or implement a policy, project management methodologies, and Behavioral Health delivery system
• Skill in 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 collaborate with others for a mutually beneficial outcome
• Ability to interpret clinical information and assess implications for treatment
• Ability to read, interpret and apply complex rules and regulations
• Ability to make independent decisions, yet know when to elevate an issue or concern
• Ability to assess variables which impact health and functioning
• Ability to make effective decisions in a high volume, fast paced environment
• Ability to write comprehensive reports
• Successfully pass fingerprint background check, prior employment verifications and reference checks
• Travel may be required for State business
• Employees who drive on state business must complete any required driver training
• Successfully complete the Electronic Employment Eligibility Verification Program (E-Verify)

Nice To Haves

• May require a valid Arizona Driver License for travel-related duties
• 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.
• Contribute clinical knowledge to assist in the resolution of quality of care concerns, clinical reviews and Operational Reviews.
• Complete 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.
• 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)
• 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
• 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