Clinical Review Unit Manager
Clinical Review Unit Manager
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Job Description
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 cost-effective 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 entry-level positions and internship opportunities AHCCCS offers meaningful career opportunities in a competitive industry.
Come join our dynamic and dedicated team.
Clinical Review Unit Manager
Division of Fee for Service Management (DFSM)
Address: 150 N. 18th Avenue Phoenix Arizona 85007
All AHCCCS employees must reside in Arizona.
Salary: $83600
Grade: 23
FLSA Status: Exempt
Closing Date: Open until filled
Under the direction of the Utilization Review (UR) Administrator this position is responsible for the management and oversight of Division of Fee for Service Management (DFSM) Clinical Review Unit (CRU) staff ensuring the timely and accurate completion of clinical reviews in various clinical units within the DFSM. Oversight includes technological aspects interaction with providers resolution of provider issues and unit reporting.
This position may offer the ability to work remotely within Arizona based upon the departments business needs and continual meeting of expected performance measures.
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:
Provides direct management of the Clinical Review Unit and manages the nursing staff and non-nursing staff. Participates in Division and Agency Policy Committees. Oversees and directs the technological aspects of the CRU processes and maintains reporting structures and processes.
Provides oversight and directs team interaction with Fee-for-Service (FFS) Providers and stakeholders ensures provider issue resolution including grievance and appeals and provides technical assistance. Works in conjunction with other clinical teams in the DFSM staff and teams in other AHCCCS divisions and external partners as required on quality related matters care coordination needs policies procedures and processes related to health care services.
Oversight of the teams participation in special processes (i.e. SMI or SED determination OHR assistance seclusion and restraint out of state placements etc.) Provides oversight and directs team interactions with FFS Providers including provider issue resolution and technical assistance.
Provides backup for the responsibilities held by the CRU nurses as needed.
Acts as a FFS subject matter expert while assisting in the development of policies and procedures as required for delivery of covered health care services.
Knowledge of:
Medical terminology
CPT and ICD procedural coding
Industry standards for retrospective utilization review prior authorization and assignment of levels of care
Medical billing guidelines
Broad scope of knowledge of clinical protocols current medical and nursing practices and alternative courses of medical treatment and expected outcomes.
Grievance proceedings and professional expert testimony
Principles and practices of administration
Concepts of program planning and design
Recognize fraudulent billing and questionable medical practices
State and Federal regulations / guidelines governing the AHCCCS FFS program
Managed care principles and quality of care improvement processes
AHCCCS claims processing system and imaging system
Skilled in:
Teaching and organizational skills
Medical assessment skills / decision making
Excellent oral and written communication
Strong interpersonal and group skills
Management skills human relations skills in order to direct staff towards an atmosphere of teamwork
Develop implement and review Medical Review policies within the AHCCCS FFS program
Plan organize and administer a health program
Resolve problems of non-compliance related to both personnel and programs
Ability to:
Interpret and administer rules and regulations related to the AHCCCS FFS program
Conduct effective training and effective meetings
Manage stressful situations such as being questioned during a judicial proceeding
Work independently with a minimal amount of supervision
Make competent judgments in the absence of higher-level supervision
Assess the AHCCCS population with a medical emphasis recognizing medical environmental and emotional conditions that influence medical conditions
Effectively evaluate program / unit / personnel performance
Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and four (4) years professional experience related to health programs appropriate to the assignment which includes program planning or administration; AND Two (2) plus years of managerial experience or (2) plus years as an AHCCCS Health Care Nursing Consultant. A Masters degree in a field appropriate to the assignment may substitute for one year of the required experience.
Preferred Qualifications: Professional experience in the health care industry in review and management of utilization prior authorization medical claims. With a certification as a professional CPT coder and/or experience in medical coding/billing. Experience working in the tribal healthcare delivery system.
Successfully pass fingerprint background check prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned 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 R.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 (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 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 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
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.
Required Experience:
Manager
Employment Type
Full-Time
