Address: 150 North 18th Avenue Phoenix Arizona 85007

This position may offer the ability to work remotely within Arizona based upon the departments 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:
Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria medical necessity and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the AHCCCS recipient.
Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed.
Performs special projects including but not limited to research projects.

Knowledge of:
Medical nursing practice medical case management protocols quality management and utilization review protocols as related to all populations including Maternal and Child Health services preventive health family planning sterilization and pregnancy termination EPSDT acute LTC chronic long-term elderly and physical disabled developmentally disabled behavioral/mental health and Tribal
Healthcare delivery system nationally and locally
Managed care processes
Acute nursing processes including assessment planning intervention and evaluation
InterQual Criteria
CCI
Coding: CPT HCPCS ICD-9
Medical Claims Review
Statistical analysis
Computer data retrieval and input
Interpretation of governmental agencies
AHCCCS Rules and Regulations
Code of Federal Regulations

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

Ability to:
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: 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.