AHCCCS

Arizona Health Care Cost Containment System
Accountability Community Innovation Leadership Passion Quality Respect Courage Teamwork

The Arizona Health Care Cost Containment System (AHCCCS) Arizonas Medicaid agency is driven by its mission to deliver comprehensive costeffective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility.

AHCCCS employees are passionate about their work committed to high performance and dedicated to serving the citizens of Arizona. Among government agencies AHCCCS is recognized for high employee engagement and satisfaction supportive leadership and flexible work environments including remote work opportunities. With career paths for seasoned professionals in a variety of fields entrylevel positions and internship opportunities AHCCCS offers meaningful career opportunities in a competitive industry.

Come join our dynamic and dedicated team.

Address: 801 E. Jefferson Street Phoenix AZ 85034

This position has the potential to work from a Virtual Office (VO) setting based on the needs of the unit and at the discretion of leadership.

Salary: $71032

Grade: 22

Closing Date: Open until filled

This position is responsible for timely and accurate claims review and adjudication to avoid penalties establishing and maintaining records and reports interacting with claims personnel for review and assessing adjudication of work process recommending edits and revision of claim charges review of system parameters and medical necessity based on standard of care and in accordance with AHCCCS Rules Regulations and Federal Guidelines.

This position may be asked to provide crossdivision support including support of clinical administration in evaluating and approving or denying payment for medical and/or behavioral health care services through prospective concurrent and retrospective review; in additional to support of the monitoring of quality management and quality assurance of FFS providers including onsite provider visits and monitoring of corrective action plans; in addition to support of prepayment review of clinical documentation for appropriateness of billing; in addition to care management support of FFS members.

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 States 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:
Monitor evaluate and approve or deny payment of medical and/or behavioral healthcare services through prospective concurrent and retrospective review. Determine medical necessity based on standards of care rules regulations policies and procedures governing the provision of covered services. Ensure timely and accurate claims or authorization reviews including timely determination for emergency criteria and/or medical necessity criteria appropriate level of care and/or length of stay determination of correct revenue/CPT/HCPC coding timely claims adjudication or timely issuance of authorization determinations. Interact with claims personnel for review and assessment of the adjudication work process recommend system edits or need to revise claim charges and review of system parameters.
Interact with other internal and external stakeholders including other department providers and tribal stakeholders as needed. Collaborate to improve compliance related to utilization management process standards AHCCCS policies and procedures and Federal and State rules and regulations.
Evaluate recommend action and provide ongoing monitoring for program policy compliance and reporting of data related to FESP or specialty services such as Specialty DME Exception NF Rates negotiated rates and Over Institutional Cost services.
Confer with Utilization Review Coordinators from the Peer Review Organizations regarding admission concurrent length of stay appropriateness of services and retrospective reviews.
Maintain documentation files prepares and submits system generated reports extracts analyses savings and trends for unit division and management.
May be asked to provide cross division support in clinical administration Quality Management/Quality Assurance Care Management and Prepayment Review in which case primary percent of time would be transitioned to that task.

Knowledge of:
Principles of utilization review
Utilization review protocols related to all member populations including Maternal and Child Health services preventive health family planning sterilization and pregnancy termination EPSDT acute LTC chronic longterm elderly and physically disabled developmentally disabled behavioral/mental health tribal and FESP
Understanding of tribal and nontribal health care delivery systems and mechanisms necessary for coordination and delivery of services
Principles and current standards of practice for the delivery emergent and nonemergent medical and/or behavioral health care
Alternative levels of care
ICD10 Diagnosis Coding; DSMIV/V; CPT procedure coding
Medical technology computer data retrieval and input
InterQual or Milliman review criteria
CCI
Interrelations of governmental agencies
Medicaid and Medicare member populations
Federal Regulations. State Statute Rule and policies applicable to AHCCCS programs
AHCCCS and ALTCS program design and implementation including case management functions and responsibilities and funding source
Familiarity with American Indian Tribes/programs and policy relative to IGAs and other related policies

Skill in:
Organizational skills that result in prioritization of multiple tasks
Interpretation of rules laws and agency policy pertaining to the AHCCCS program
Good written and communication skills
Computer skills
Utilization Review skills
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
Public relations skills interacting with statewide providers of healthcare services public organizations and social 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 specific patterns initiate investigations submit findings and recommendations
Strong Interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds

Ability to:
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
Work Virtual Office or Telecommute or both
Interpret and apply medical and claims policies
Read and interpret medical documentation
Evaluate medical documentation for emergency criteria medical necessity correct CPT coding
Determine appropriate hospital levels of care and lengths of stay
Respond to inquiries for UR/CPT coding decisions
Maintain data for monthly reports
Work independently with minimal supervision

Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and 3 years experience in health care delivery systems.

Preferred: Experience in concurrent and retrospective review; CCI lnterQual HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.

Successfully pass fingerprint background check prior employment verifications and reference checks; employment is contingent upon completion of the abovementioned process and the agencys 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 R210207.12.

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:Drivers License Requirements.

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

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 parttime employees)
Paid Parental LeaveUp to 12 weeks per year paid leave for newborn or newlyplaced foster/adopted child. Learn more about the Paid Parental Leave pilot program here.
Other Leaves Bereavement civic duty and military.
A topranked 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 fulltime or parttime 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 programhere. 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 lifelong income upon retirement.
Required participation for LongTerm Disability (LTD) and ASRS Retirement plan.
Pretaxed payroll contributions begin after a 27week waiting period (prior contributions may waive the waiting period).

Deferred Retirement Compensation Program
Voluntary participation.
Program administered through Nationwide.
Taxdeferred 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
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.