Address: 150 North 18th Avenue Phoenix, Arizona 85007

This position may offer the ability to work remotely within Arizona based upon the department's needs and continual meeting of expected performance measures.

All AHCCCS Employees must reside within the state of Arizona.

Salary: $71,032

FLSA Status: Exempt

Grade: 22

Closing Date: Open until Filled

This position will provide monitoring and technical assistance to ensure compliance with contractual, regulatory, and statutory obligations for FFS members’ physical/acute care services and behavioral health needs. Monitor over and under utilization, conduct reviews, provide oversight and technical assistance, gather, plan, organize and evaluate information from multiple sources, including utilization data, case file reviews and audits. Coordinate care with external and internal stakeholders as needed, make referrals as necessary, participate in clinical staffing as needed, serve as a resource for medically necessary covered services.

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.

Major duties and responsibilities include but are not limited to:
• Review clinical documentation to monitor, evaluate and authorize healthcare services. Review for medical necessity, appropriateness of services, quality of care, and compliance with contractual State and Federal obligations governing the provision of covered behavioral and physical healthcare services.
• Obtain, review, analyze, and discuss report and data findings in order to identify, monitor, and evaluate specialized intervention strategies and outcomes for member populations, including SMI, and TRBHA.
• Collaborate with AHCCCS providers including SMI clinic, TRBHA, Medical Home or other treatment team members in order to provide technical assistance, training, & consultation on As needed, provides backup for the responsibilities held by the BH Prior Authorization/Utilization Review unit & other CMSU functions as needed.
• Coordinate with internal and external customers as needed, make referrals as necessary, participate in clinical staffing as needed, serve as a FFS health plan subject matter expert.
• Assist in the development of policies and procedures as required for delivery of covered behavioral health services.

Knowledge:
• Service Authorization concepts, principles, and strategies
• Behavioral health service delivery system and the needs of individuals designated as SMI
• Principles of behavioral health and medical nursing management and assessment
• Individual service planning process and substance abuse treatment
• HCPCS codes Levels I & II and, knowledge of International Classification of Diseases, DSM IV/V coding and medical billing guidelines
• Medical technology, computer data retrieval and input, including EHR, HIE, etc
• Medicaid and Medicare Federal Regulations, State Statute, Rules, and Policies applicable to AHCCCS programs
• AHCCCS program design and implementation, prior authorization functions and responsibilities, provider network, and funding source
• Familiarity with American Indian Tribes, programs and policy

Skills:
• Problem solving identification, evaluation, and imitation of appropriate action, nursing, and case management assessment
• Excellent verbal/written communication skills, with FFS Providers
• Organizational skills to coordinate, monitor and report on multiple cases simultaneously
• Analytical skills to identify and correlate specific patterns, initiate investigations, submit findings and recommendations
• Strong interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds
• Documentation and reporting of data and trends

Abilities:
• Strong ability to collaborate with others for mutually beneficial outcomes
• Interpret clinical information and assess implications for treatment
• Read, interpret, and apply complex rules and regulations
• Independent decision making yet knowing when to elevate the decision

Arizona Driver's License

Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and three (3) year of relevant experience.

Preferred: Professional experience in the Healthcare Industry - specifically experience in Prior Authorization, Concurrent Review, Retrospective Review, and Utilization Management.

• 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.)

If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements.

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Among the many benefits of a career with the State of Arizona, there are:
• 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

By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.

Learn more about the Paid Parental Leave pilot program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page

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.

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.
Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.