ALTCS PA/UR Consultant

AHCCCSArizona Health Care Cost Containment System Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s 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.ALTCS Prior Authorization Utilization Review ConsultantDivision of Fee for Service Management (DFSM)Job Location:Address: 150 North 18th Avenue Phoenix, Arizona 85007This position may offer the ability to work remotely, within Arizona, based upon the department's business needs and continual meeting of expected performance measures.All AHCCCS Employees must reside within the state of Arizona.Posting Details:Salary: $71,032FLSA Status: ExemptGrade: 22Closing Date: Open until filledJob Summary:This position will review Prior Authorization (PA) requests and determine medical necessity for Physical, and/or Behavioral Health Services (including Children's Rehabilitative Services [CRS]), for the Division of Developmental Disabilities (DDD) Tribal Health Plan (THP) population and approve or deny PA requests. This position also provides support to Arizona Department of Economic Security/ Division of Developmental Disabilities (DES/DDD) THP staff, Fee For Service (FFS) providers, tribal stakeholders, and AHCCCS staff while following guidelines, standard of care, 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 State’s 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, policies, and procedures governing the provision of covered services. • Collaborates with providers, Tribes, DES/DDD, and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, work flow, complex member needs, and other issues. • Provides education and technical assistance to FFS Providers, Tribal Staff, and AZDES/DDD as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies and procedures. • Evaluates, recommends action, negotiates rates, and provides on-going monitoring or program policy compliance and reporting of data related to specialty services such as Specialty DME, and Exception NF Rates. • Participates in process improvement and other special projects, work groups and committees to improve the efficiency of care coordination, utilization management and other unit functions. • Tracks and/or performs reviews for compliance related to utilization management processes and Federal and State rules and regulations related to the AHCCCS THP populations. • Devises and submits system generated reports, extracts, and analyses for unit, division, and management. Maintains documentation files.Knowledge, Skills & Abilities (KSAs):Knowledge of: • Principles of medical and/or behavioral management and assessment • 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 physically disabled, developmentally disabled, behavioral/mental health • Current costs, appropriateness and utilization of medical supplies and equipment • Understanding of health care delivery systems and mechanisms necessary for coordination and delivery of services • Managed care processes Acute nursing processes including assessme