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: $71032

FLSA Status: Exempt

Grade: 22

Closing Date: Open until filled

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 position determines medical necessity based on standards of care rules 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 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:
Collaborates with providers Tribal and AHCCCS staff regarding care coordination utilization review prior authorization coverage criteria policies and procedures workflow member needs and other issues.
Evaluates recommends action negotiates rates and provides 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.
Confers with Utilization Review Coordinators from the Peer Review Organization regarding concurrent review of length of stay and appropriateness of services.
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.
Tracks and/or performs focused reviews for compliance related to utilization management processes and Federal and State Rules and Regulations related to the AHCCCS FFS populations. Maintain documentation files.
Devises and submits system generated reports extracts and analyses for unit and division and management
Participates in process improvement and other special projects work groups and committees to improve the efficiency of care coordination utilization management and other functions in the Clinical Administration unit.

Knowledge of:
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/non-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 policies and procedures
Code of Federal Regulation (42 CFR)
Medical and psycho- social needs of ALTCS members cultural environmental and community influences on behavior of ALTCS members
AHCCCS and ALTCS program design and implementation including case management functions and responsibilities provider network and funding source
Familiarity with American Indian Tribes/ programs and policy relative to IGAs and other related policies

Skill in:
Problem solving-identification; evaluation and initiation of appropriate action; nursing assessment
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

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.

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 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.