Address: 150 North 18th Avenue Phoenix Arizona 85007

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

All AHCCCS Employees must reside within the state of Arizona.

Salary: $72132

FLSA Status: Exempt

Grade: 22

Closing Date: Open until filled

This position is responsible to monitor evaluate and approve/deny the payment of medical and/or behavioral healthcare (BH) servicesthrough prospective concurrent and retrospective review for the AHCCCS ALTCS Fee for Service populations. It is accountable for theprevention and/or resolution of utilization problems adversely affecting the balance between quality of care cost effectiveness andminimization of risk through the use of the utilization management review process.

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:
Review clinical documentation performs 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 and policies and procedures governing the provision of covered services.
Work directly and collaborates with providers Tribal Programs and AHCCCS staff to resolve issues regarding care coordination utilization review prior authorization coverage criteria policies and procedures workflow member needs to support quality outcomes and other issues. Provides education and technical assistance to FFS Providers and Tribal Staff as needed including identification research and resolution of member specific and provider issues to improve compliance with AHCCCS requirements policies and procedures.
Monitors specialized programs such as Home Modifications and approvals for participation or payment and reporting of member data. Participates in audits process improvement and other special projects work groups and committees to improve the efficiency of care coordination UM and reporting accuracy and other unit functions.
Evaluates rates and compliance for Specialty and high-cost services (e.g. DME long term care requests) recommends action and provides on-going monitoring or program policy compliance and reporting of data related to specialty services such as Specialty DME Exception NF Rates and Over Institutional Cost services.
Maintain records prepare reports and ensure compliance with all regulatory and policy requirements. Tracks and/or performs reviews for compliance related to utilization management processes and Federal and State rules and regulations related to the AHCCCS FFS populations. Devises and submits system generated reports extracts and analyses to unit and division management. Maintains documentation files.

Knowledge of:
Understanding of healthcare delivery systems mechanisms necessary for coordination and delivery of services
Principles of medical and/or behavioral management and assessment
Current standards of medical and/or behavioral practice delivery of medical/behavioral care
Current costs appropriateness & utilization of medical supplies & equipment
Principles of utilization review
Alternate levels of care
ICD-9/10 diagnosis coding; DFM-IVN Diagnosis Coding; CPT procedure coding
Medical terminology computer retrieval and input
Interrelations of government agencies AHCCCS ALTCS Medicaid & Medicare Federal Regulations State Statute rules and policies applicable to AHCCCS programs policies & procedures
Code of Federal Regulations (42 CFR)
Medical and psycho-social needs of ALTCS members cultural environmental and community influences on behavior of ALTCS members
Familiarity with American Indian Tribes/Programs & policy relative to IGAs

Skill in:
Problem solving-identification; evaluation initiation of appropriate action; nursing assessment
Proficiency in oral and written communication
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:
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 & regulations
Independent decision making
Implement AHCCCS & ALTCS program design including case management functions and responsibilities provider network and funding source

Arizona Drivers 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 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.