BH 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.Behavioral Health 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: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 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: • 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, Skills & Abilities (KSAs):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 careICD-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