The Medical Services Manager is responsible for the daily oversight of the health and dental programs for the Department of Child Safety's (DCS) Comprehensive Health Plan (CHP), including planning and evaluation of utilization review functions and decision-making. This position participates as a member of the management team regarding complex cases across disciplines and ensures compliance with requirements per the State Contract including the application of appropriate medical necessity criteria, concurrent review, discharge planning, prior authorization, continuity of care and care management activities. The Medical Service Manager assists with the review and analysis of both medical management data and quality initiatives for potential areas of concern, needed improvement, over and underutilization, consistency in use of evidence-based practices, and implementation of corrective action plans and training updates, as needed. In addition, this position works cross functionally to improve patient outcomes and satisfaction, control the cost of care, reduce unnecessary readmissions and utilization, and improve the overall quality and health outcomes of the children/youth enrolled in the plan.
-Manages staff in a select area of the DCS CHP healthcare delivery system (physical and dental health) including Registered Nurses and Clinical Care Coordinators. Responsible for daily review and monitoring of team’s work flows and processes to ensure that they meet plan, policy, and compliance standards within the medical management area. Monitors timeliness of utilization activities.
-Conducts and collaborates on clinical case reviews, medical consultations, Child and Family Team (CFT) meetings and care conferences as well as participates in on-call rotation and handling incoming inquiries from members, providers, caregivers and DCS staff.
-Creates, edits and revises policies annually, as well as, assists team with monthly, quarterly, and annual deliverables as determined by AHCCCS. Formulates and updates plans and priorities to address any departmental or operational challenges.
-Hires, trains, coaches and audits the Medical Management Team. Acts as a clinical reviewer and mentor on complex cases including pharmacy or service prior authorizations as well as case review on high utilization members or risk management cases as needed.
-Implements and evaluates the Medical Management program and work plan in accordance with DCS mission and strategic goals, as well as federal and state laws and regulations. Resolves and communicates utilization management issues and concerns, corrective action plan activities and reporting.
-Participates in joint operating meetings with DCS CHP's contracted health plan and assists with clinical projects and plans. Collaborates to assure integration, quality and efficiency of utilization management.
-Reviews and analyzes health data, including inpatient, outpatient, and pharmacy data to identify trends, potential areas requiring system updates/changes and training opportunities (internal and external). Reviews, analyzes, and reports utilization metrics.
-Facilitating or leads various committees' structures. Presents at the Quality Management and Medical Management Committees. Leads review of regulatory standards impacting Utilization Management/Prior Authorization. Represents Medical Management in external meetings and activities.
- Utilization Management practices and programs (including Prior Authorization)
- Leadership and organizational principles, oversight and regulatory methodologies, and managed care delivery systems.
- State legislative laws, regulations and rules related to behavioral health care and child welfare
- Pediatric care programs and clinical standards
- Evidence-based criteria
- Principles of managed care, Arizona Health Care Cost Containment System (AHCCCS) and Medicaid
- Direct management and coaching
- Prioritizing numerous responsibilities and effectively managing time to meet deadlines
- Utilizing computer software and applications such as Microsoft Office Word, Excel, and PowerPoint
- Applying the principles of management
- Analysis and decision-making
- Clinical problem-solving/trouble-shooting
- Verbal and written presentation and communication
- Meet deadlines
- Lead a team including cross functional departments
- Plan, analyze, and coordinate activities
- Implement strategic plan for Medical Management
- Navigate Information Systems
- Remain up-to-date on clinical criteria and AHCCCS policies/procedures
- Represent DCS within the community and state regarding health issues for children/youth in foster care
Independently licensed physical and/or behavioral health clinician with ability to practice under an unrestricted AZ license: Registered Nurse (RN), Nurse Practitioner (NP), Physician (MD/DO).
A minimum of five (5) years' nursing experience or the equivalent.
The ability to secure and maintain clearance from the DCS Central Registry.
As an employee of the Department of Child Safety you will be entitled to a comprehensive benefits package that can become effective as soon as two weeks after starting!
- Paid sick leave.
- Paid vacation that includes ten (10) holidays per year.
- Competitive health and dental insurance plans.
- Life insurance and long-term disability insurance.
We also offer optional employee benefits that include:
- Vision coverage.
- Short-term disability insurance.
- Deferred compensation plans.
- Supplemental life insurance.
- Employee wellness plans
DCS offers a Bi-Lingual Stipend to all interested and eligible DCS Employees who successfully complete a language proficiency exam. Qualifying employees will receive a $500 annual stipend paid in equal increments.
For a complete list of benefits provided by The State of Arizona, please visit our benefits page
Positions in this classification participate in the Arizona State Retirement System (ASRS).
Enrollment eligibility will become effective after 27 weeks of employment.
Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by contacting 602-255-2903.
Requests should be made as early as possible to allow time to arrange the accommodation. Arizona State Government is an AA/EOE/ADA Reasonable Accommodation Employer.
ARIZONA MANAGEMENT SYSTEM (AMS)
All Arizona state employees operate within the Arizona Management System (AMS), an intentional, results-driven approach for doing the work of state government whereby every employee reflects on performance, reduces waste, and commits to continuous improvement with sustainable progress. Through AMS, every state employee seeks to understand customer needs, identify problems, improve processes, and measure results.
State employees are highly engaged, collaborative and embrace a culture of public service.
The State of Arizona is an Equal Employment Opportunity Employer.