ALTCS PA/UR Consultant
Arizona State Government, Phoenix, AZ, United States
ALTCS Prior Authorization Utilization Review Consultant
Division of Fee for Service Management (DFSM)
Job Location: 150 North 18th Avenue Phoenix, Arizona 85007. The position may offer the ability to work remotely within Arizona, based upon the department's business needs and continual meeting of expected performance measures. All AHCCCS Employees must reside within the state of Arizona.
Posting Details Salary: $71,032. FLSA Status: Exempt. Grade: 22. Closing Date: Open until filled.
Job Summary This position will review Prior Authorization (PA) requests and determine medical necessity for Physical, and/or Behavioral Health Services (including Children's Rehabilitative Services [CRS]), for the Division of Developmental Disabilities (DDD) Tribal Health Plan (THP) population and approve or deny PA requests. This position also provides support to Arizona Department of Economic Security/ Division of Developmental Disabilities (DES/DDD) THP staff, Fee For Service (FFS) providers, tribal stakeholders, and AHCCCS staff while following guidelines, standard of care, regulations, policies, and procedures governing the provision of 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. 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, perform prospective, concurrent and retrospective reviews for medical necessity, appropriateness for admission, length of stay, level of care, quality of care, coordination of care based on State and Federal regulations, policies, and procedures governing the provision of covered services.
Collaborate with providers, Tribes, DES/DDD, and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, work flow, complex member needs, and other issues.
Provide education and technical assistance to FFS Providers, Tribal Staff, and AZDES/DDD as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies and procedures.
Evaluate, recommend action, negotiate rates, and provide ongoing monitoring or program policy compliance and reporting of data related to specialty services such as Specialty DME, and Exception NF Rates.
Participate in process improvement and other special projects, work groups and committees to improve the efficiency of care coordination, utilization management and other unit functions.
Track and perform reviews for compliance related to utilization management processes and Federal and State rules and regulations related to the AHCCCS THP populations.
Devises and submits system generated reports, extracts, and analyses for unit, division, and management. Maintains documentation files.
Knowledge, Skills & Abilities (KSAs) Knowledge of:
Principles of medical and/or behavioral management and assessment
Medical/nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, behavioral/mental health
Current costs, appropriateness and utilization of medical supplies and equipment
Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services
Managed care processes
Acute nursing processes including assessment, planning, intervention and evaluation
ICD-9/10 Diagnosis Coding; DSM-IV/V; CPT procedure coding
Medical technology computer data retrieval and input
Interrelations of governmental agencies
AHCCCS, ALTCS, Medicaid and Medicare Federal Regulations. State Statute and Rule and policies applicable to AHCCCS programs, policies and procedures
Code of Federal Regulation (42 CFR)
Skill in:
Organizational skills for setting priorities; workload, record keeping, and prioritization of multiple tasks
Interpretation of rules, laws and agency policy pertaining to the AHCCCS program
Good written and verbal communication skills
Computer skills
Utilization Review and Medical Claims Review skills
Producing work products with limited supervision
Effectively collaborating with people in positions of all levels
Research and analysis
Team player and can work independently
Ability to:
Interpret and apply medical and claims policy
Evaluate medical documentation for emergency criteria, medical necessity, and correct CPT coding
Document rationale for UR/CPT coding decisions
Negotiate competitive rates to maximize available funding for members' care
Determine appropriate hospital levels of care and lengths of stay
Respond to inquiries and grievances and answer utilization review questions
Independent decision making
Selective Preference(s) 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.
Preferred:
Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served.
Pre-Employment Requirements
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).
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
Retirement
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.
Contact Us 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.
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Posting Details Salary: $71,032. FLSA Status: Exempt. Grade: 22. Closing Date: Open until filled.
Job Summary This position will review Prior Authorization (PA) requests and determine medical necessity for Physical, and/or Behavioral Health Services (including Children's Rehabilitative Services [CRS]), for the Division of Developmental Disabilities (DDD) Tribal Health Plan (THP) population and approve or deny PA requests. This position also provides support to Arizona Department of Economic Security/ Division of Developmental Disabilities (DES/DDD) THP staff, Fee For Service (FFS) providers, tribal stakeholders, and AHCCCS staff while following guidelines, standard of care, regulations, policies, and procedures governing the provision of 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. 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, perform prospective, concurrent and retrospective reviews for medical necessity, appropriateness for admission, length of stay, level of care, quality of care, coordination of care based on State and Federal regulations, policies, and procedures governing the provision of covered services.
Collaborate with providers, Tribes, DES/DDD, and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, work flow, complex member needs, and other issues.
Provide education and technical assistance to FFS Providers, Tribal Staff, and AZDES/DDD as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies and procedures.
Evaluate, recommend action, negotiate rates, and provide ongoing monitoring or program policy compliance and reporting of data related to specialty services such as Specialty DME, and Exception NF Rates.
Participate in process improvement and other special projects, work groups and committees to improve the efficiency of care coordination, utilization management and other unit functions.
Track and perform reviews for compliance related to utilization management processes and Federal and State rules and regulations related to the AHCCCS THP populations.
Devises and submits system generated reports, extracts, and analyses for unit, division, and management. Maintains documentation files.
Knowledge, Skills & Abilities (KSAs) Knowledge of:
Principles of medical and/or behavioral management and assessment
Medical/nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, behavioral/mental health
Current costs, appropriateness and utilization of medical supplies and equipment
Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services
Managed care processes
Acute nursing processes including assessment, planning, intervention and evaluation
ICD-9/10 Diagnosis Coding; DSM-IV/V; CPT procedure coding
Medical technology computer data retrieval and input
Interrelations of governmental agencies
AHCCCS, ALTCS, Medicaid and Medicare Federal Regulations. State Statute and Rule and policies applicable to AHCCCS programs, policies and procedures
Code of Federal Regulation (42 CFR)
Skill in:
Organizational skills for setting priorities; workload, record keeping, and prioritization of multiple tasks
Interpretation of rules, laws and agency policy pertaining to the AHCCCS program
Good written and verbal communication skills
Computer skills
Utilization Review and Medical Claims Review skills
Producing work products with limited supervision
Effectively collaborating with people in positions of all levels
Research and analysis
Team player and can work independently
Ability to:
Interpret and apply medical and claims policy
Evaluate medical documentation for emergency criteria, medical necessity, and correct CPT coding
Document rationale for UR/CPT coding decisions
Negotiate competitive rates to maximize available funding for members' care
Determine appropriate hospital levels of care and lengths of stay
Respond to inquiries and grievances and answer utilization review questions
Independent decision making
Selective Preference(s) 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.
Preferred:
Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served.
Pre-Employment Requirements
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).
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
Retirement
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.
Contact Us 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.
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