BH PA/UR Consultant
Arizona State Government, Phoenix, AZ, United States
AHCCCS
Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver cost‑effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model and has received multiple awards for workplace effectiveness and flexibility.
Job Title
Behavioral Health Prior Authorization Utilization Review Consultant
Division: Fee for Service Management (DFSM)
Job Location
150 North 18th Avenue, Phoenix, Arizona 85007. Remote work within Arizona may be offered based on business needs.
Posting Details
Starting salary $71,032, may increase with experience.
FLSA Status: Exempt
Grade: 22
Closing Date: Open until filled
Job Summary
The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review for the fee‑for‑service population. The role determines medical necessity based on standards of care, rules, regulations, policies and procedures.
Major Duties and Responsibilities
Collaborate with providers, Tribal and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs, and other issues.
Evaluate, recommend action, negotiate rates, and provide ongoing monitoring for program policy compliance and reporting of data related to specialty services such as Specialty DME, Exception NF Rates, and Over Institutional Cost services.
Coordinate with Utilization Review Coordinators from the Peer Review Organization regarding concurrent review of length of stay and appropriateness of services.
Provide education and technical assistance to FFS providers and Tribal staff as needed, including identification, research and resolution of member‑specific and provider issues.
Track and perform focused reviews for compliance related to utilization management processes and federal and state rules and regulations; maintain documentation files.
Devises and submits system‑generated reports, extracts, and analyses for unit, division and management.
Participate in process improvement and special projects, work groups, and committees to improve the efficiency of care coordination, utilization management, and related functions.
Knowledge
Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services.
Principles of medical and/or behavioral management and assessment.
Current standards of medical/behavioral practice and delivery of acute
on‑acute medical/behavioral care.
Current costs, appropriateness and utilization of medical supplies and equipment.
Principles of utilization review.
Alternative levels of care.
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.
Code of Federal Regulations (42 CFR).
Medical and psychosocial needs of ALTCS members, cultural, environmental, and community influences on behavior.
AHCCCS and ALTCS program design and implementation, including case management functions, provider network, and funding source.
Familiarity with American Indian Tribes programs and policy relative to IGA’s and related policies.
Skills
Problem solving – identification, evaluation, and initiation of appropriate action; nursing assessment.
Public relations skills, interacting with statewide providers and community agencies.
Organizational skills for setting priorities, workload, and record keeping.
Intermediate computer skills to access and input member information.
Analytical ability to identify and correlate patterns, initiate investigations, submit findings and recommendations.
Strong interpersonal skills working with diverse cultures and socioeconomic backgrounds.
Abilities
Proficiency in oral and written communication.
Teach and train.
Interpret clinical information and assess implications for treatment.
Negotiate competitive rates to maximize available funding for members’ care.
Read, interpret, and apply complex rules and regulations.
Independent decision‑making.
Selective Preferences – Minimum
Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and have 3 years of relevant healthcare experience. Valid Arizona Driver License may be required for travel duties.
Selective Preferences – 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.
Travel may be required for State business. Employees who drive on state business must complete required driver training.
All newly hired State employees 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).
Paid parental leave up to 12 weeks per year.
Other leaves – bereavement, civic duty, military.
Top‑ranked retirement program with lifetime pension benefits.
Robust and affordable insurance plan – medical, dental, life, and disability.
Eligibility for Public Service Loan Forgiveness Program (must meet qualifications).
RideShare and Public Transit Subsidy.
Learning and career development opportunities.
Retirement
Lifetime Pension Benefit Program administered through the Arizona State Retirement System.
Deferred Retirement Compensation Program – voluntary participation, tax‑deferred investments through payroll deductions.
EEO Statement
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. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.
#J-18808-Ljbffr
Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver cost‑effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model and has received multiple awards for workplace effectiveness and flexibility.
Job Title
Behavioral Health Prior Authorization Utilization Review Consultant
Division: Fee for Service Management (DFSM)
Job Location
150 North 18th Avenue, Phoenix, Arizona 85007. Remote work within Arizona may be offered based on business needs.
Posting Details
Starting salary $71,032, may increase with experience.
FLSA Status: Exempt
Grade: 22
Closing Date: Open until filled
Job Summary
The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review for the fee‑for‑service population. The role determines medical necessity based on standards of care, rules, regulations, policies and procedures.
Major Duties and Responsibilities
Collaborate with providers, Tribal and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs, and other issues.
Evaluate, recommend action, negotiate rates, and provide ongoing monitoring for program policy compliance and reporting of data related to specialty services such as Specialty DME, Exception NF Rates, and Over Institutional Cost services.
Coordinate with Utilization Review Coordinators from the Peer Review Organization regarding concurrent review of length of stay and appropriateness of services.
Provide education and technical assistance to FFS providers and Tribal staff as needed, including identification, research and resolution of member‑specific and provider issues.
Track and perform focused reviews for compliance related to utilization management processes and federal and state rules and regulations; maintain documentation files.
Devises and submits system‑generated reports, extracts, and analyses for unit, division and management.
Participate in process improvement and special projects, work groups, and committees to improve the efficiency of care coordination, utilization management, and related functions.
Knowledge
Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services.
Principles of medical and/or behavioral management and assessment.
Current standards of medical/behavioral practice and delivery of acute
on‑acute medical/behavioral care.
Current costs, appropriateness and utilization of medical supplies and equipment.
Principles of utilization review.
Alternative levels of care.
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.
Code of Federal Regulations (42 CFR).
Medical and psychosocial needs of ALTCS members, cultural, environmental, and community influences on behavior.
AHCCCS and ALTCS program design and implementation, including case management functions, provider network, and funding source.
Familiarity with American Indian Tribes programs and policy relative to IGA’s and related policies.
Skills
Problem solving – identification, evaluation, and initiation of appropriate action; nursing assessment.
Public relations skills, interacting with statewide providers and community agencies.
Organizational skills for setting priorities, workload, and record keeping.
Intermediate computer skills to access and input member information.
Analytical ability to identify and correlate patterns, initiate investigations, submit findings and recommendations.
Strong interpersonal skills working with diverse cultures and socioeconomic backgrounds.
Abilities
Proficiency in oral and written communication.
Teach and train.
Interpret clinical information and assess implications for treatment.
Negotiate competitive rates to maximize available funding for members’ care.
Read, interpret, and apply complex rules and regulations.
Independent decision‑making.
Selective Preferences – Minimum
Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and have 3 years of relevant healthcare experience. Valid Arizona Driver License may be required for travel duties.
Selective Preferences – 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.
Travel may be required for State business. Employees who drive on state business must complete required driver training.
All newly hired State employees 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).
Paid parental leave up to 12 weeks per year.
Other leaves – bereavement, civic duty, military.
Top‑ranked retirement program with lifetime pension benefits.
Robust and affordable insurance plan – medical, dental, life, and disability.
Eligibility for Public Service Loan Forgiveness Program (must meet qualifications).
RideShare and Public Transit Subsidy.
Learning and career development opportunities.
Retirement
Lifetime Pension Benefit Program administered through the Arizona State Retirement System.
Deferred Retirement Compensation Program – voluntary participation, tax‑deferred investments through payroll deductions.
EEO Statement
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. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.
#J-18808-Ljbffr