Quality Management Nursing Consultant

Arizona Department of Administration•Phoenix, AZ

3d•$71,032•Hybrid

About The Position

The Quality Management Nursing Consultant works independently in the Division of Fee for Service Management (DFSM), applying clinical knowledge, judgment, and expertise to assess, coordinate, and monitor service delivery. The consultant conducts comprehensive assessments of provider resources and individual members, reviews case materials for compliance with state and federal regulations and policies, resolves assigned cases promptly, and identifies systemic issues for AHCCCS to address. The position monitors quality management processes and concerns, including quality of care and health and safety issues. It contributes clinical expertise to clinical reviews and operational reviews, evaluates data management and other deliverables for compliance, and follows up on reports, action plans, and provider education. The consultant also conducts on-site investigations, develops and evaluates population-specific outcome metrics, leads projects and reviews, and provides education and technical assistance to stakeholders. This is a hybrid position based in Phoenix or Tucson, with some in-office meetings and on-site investigations for at least 20% of work time. Urgent investigations or reviews may occasionally occur outside normal business hours and on weekends. Work, including remote work, must be performed within Arizona unless an exception is authorized in advance. 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.
Possess knowledge of state and federal policies and procedures governing Title XIX, Title XXI, managed care, and long-term care supports and services.
Know current standards of medical and behavioral practice and modes of delivery for acute and non-acute care and services.
Know data management and utilization review regulations, rules, and processes.
Know AHCCCS and Medicaid regulations, policies, and procedures, and applicable federal and state statutes, regulations, and rules.
Know medical and nursing practice, case management protocols, and utilization review protocols related to acute care, long-term care, chronic long-term care for elderly and physically disabled populations, developmental disabilities, and behavioral and mental health.
Know case management development, implementation, and ongoing review.
Demonstrate acute nursing and clinical process skills, including assessment, planning, intervention, and evaluation, as well as clinical assessment skills.
Use techniques to analyze, develop, or implement policies; project management methodologies; and knowledge of the behavioral health delivery system.
Apply problem-solving, evaluation, and appropriate-action initiation techniques.
Demonstrate excellent verbal and written communication, organizational and record-keeping skills, and strong interpersonal skills with agency management and people from diverse cultural and socioeconomic backgrounds.
Use project management skills to meet goals and deadlines, along with research, analytical, documentation, and reporting skills.
Collaborate with others toward mutually beneficial outcomes.
Interpret clinical information and assess implications for treatment; read, interpret, and apply complex rules and regulations.
Make independent decisions while recognizing when to elevate an issue or concern; assess variables affecting health and functioning; make effective decisions in a high-volume, fast-paced environment; and write comprehensive reports.
May need a valid Arizona driver license for travel-related duties.
Successfully pass a fingerprint background check, prior employment verifications, and reference checks; employment is contingent on completion of these checks and the agency’s ability to reasonably accommodate any restrictions.
Complete required driver training if driving on state business, where applicable.
Successfully complete E-Verify employment eligibility verification.

Nice To Haves

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

Responsibilities

Monitor compliance with state and federal regulations related to quality management processes, and track and trend quality-of-care and health-and-safety concerns.
Receive, research, document, and resolve quality-of-care and health-and-safety issues using standardized processes.
Track case status in a centralized database to support accurate, timely completion and appropriate referrals.
Research and resolve assigned issues promptly and identify systemic issues for AHCCCS to address.
Contribute clinical knowledge to quality-of-care concern resolution, clinical reviews, and operational reviews.
Independently review data management and other deliverables, technical assistance, and focused studies or reviews, including those concerning the behavioral health delivery system, for compliance with contractual and policy requirements.
Follow up on written reports, action plans, provider education, and related actions as appropriate.
Conduct on-site investigations concerning health and safety, immediate jeopardy, and other AHCCCS initiatives; urgent visits may occur outside normal business hours and on weekends.
Protect the quality of care provided to AHCCCS members, including member dignity and respect, consideration of special health care needs, timely correspondence, and resolution of concerns.
Use independent judgment to research data, determine case status, select interventions, and reach appropriate resolutions.
Develop improved unit processes and procedures, lead special projects and reviews to meet timelines, and provide ongoing updates to management.
Develop population-specific outcome metrics and track, evaluate, analyze, and revise them as needed based on member data.
Provide accurate and consistent education and technical assistance to internal and external stakeholders about covered services and contractual or policy requirements.

Benefits

10 paid holidays per year.
Paid vacation and sick leave (13 and 12 days per year, respectively), accruing from the first day of employment; 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.
A 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.
Optional remote work arrangements, subject to management approval and agency discretion.
Voluntary deferred retirement compensation program through Nationwide, with tax-deferred payroll-deduction investments.