AHCCCS

Address:  801 E. Jefferson Street, Phoenix, AZ 85034

This position may offer the ability to work remotely within Arizona based upon the department's needs and continual meeting of expected performance measures. There are also times that site & office visits may be required.

Salary: $72,132 (Standard Salary)

Grade: 22

Closing Date: Open until all positions are filled  

The Division of Fee For Service Management (DFSM) is looking for a highly motivated individual to join our team as a Prepayment Nurse. This position will work independently to ensure compliance with regulations and policies and provide timely resolution of multiple cases assigned. This position will also be responsible for identifying systemic issues for AHCCCS to address. This position will be hybrid with some in-office meetings and on-site investigations and reviews as needed. Occasionally, this position may also participate as needed in urgent on-site investigations and reviews outside of normal business hours and weekends.

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 documents submitted to support claims for compliance with State and Federal regulations. Receive, research, document, billing discrepancies. Conduct audits. Track, trend, and monitor the status to ensure accurate and timely completion and make appropriate referrals to report fraud, waste and abuse.
• Ensure research and resolution of issues or concerns promptly as assigned and identify systemic issues for AHCCCS to address.
• Contributes clinical knowledge to review documentation submitted to support billed claims. Determines if claims should be adjudicated based on the clinical content of submitted documentation. Adjudicated claims based on the review. Ensures clinical reviews correspond to compliance with contractual and policy requirements for all lines of business.
• Develop improved processes and procedures to improve the efficiency of the unit. Lead special projects and reviews to ensure completion within the designated timelines. Provide ongoing updates to Management. 
• Identify possible member Quality of Care (QOC) concerns during the review of documentation, relay that information to management and/or complete a QOC referral and submit the referral to the appropriate Quality Management contact.
• Provide education and technical assistance to internal and external stakeholders, as appropriate, regarding covered services, and contractual or policy requirements, accurately and consistently to improve compliance with AHCCCS requirements and improve quality of care and service to AHCCCS members.
• Develop metrics for claims-specific outcome objectives. Tracking, evaluation, analysis, and revision of metrics as needed based on the ongoing analysis of member data.
• Conduct on-site investigations regarding possible health and safety concerns, immediate jeopardy situations, and other situations supporting AHCCCS initiatives and ventures. Occasionally, an immediate jeopardy situation may occur outside of normal business hours and weekends.

Knowledge of:
• State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, and LTC Supports and Services
• Current standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care/services
• Data management and utilization review regulations, rules and processes
• AHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules
• Medical/nursing practice, medical case management protocols, utilization review protocols as related to the acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, and behavioral/mental health
•  Knowledge of standards for documentation of behavioral health assessments, treatment planning, and progress notes.

Skills in:
• Acute nursing and clinical processes including assessment, planning, intervention, and evaluation
• Clinical assessment skill
• Techniques to select a particular approach to analyze develop or implement a policy, project management methodologies, and Behavioral Health delivery system
• Problem-solving techniques, evaluation, and initiation of appropriate action 
• Excellent communication, verbal and written
• Organizational skills for setting priorities, workload, and record keeping
• Strong interpersonal skills in working with agency management, and people of diverse cultures and socioeconomic background
• Project management to meet goals and deadlines
• Research and analytical skills
• Documentation and reporting of data and trends

Ability to:
• Strong ability to collaborate with others for a mutually beneficial outcome 
• Interpret clinical information and assess implications for treatment
• Read, interpret and apply complex rules and regulations
• Independent decision making, yet knowing when to elevate an issue or concern
• Assess variables which impact health and functioning
• Make effective decisions in a high volume, fast paced environment

Currently in procession of a valid Arizona Driver's License.

Minimum:

• Possession of a current license to practice as a registered nurse in the State of Arizona and three (3) years of relevant healthcare experience.

Preferred:

• Preference given to Internal AHCCCS employees
• At least one year professional healthcare industry experience in Quality or Utilization Management; OR experience in the behavioral health field, preferably in the context of the delivery of service in Arizona’s public behavioral health system.
• At least one year experience working in a managed care environment.
• Case Management, Quality Management, Utilization Management and/or social work experience.
• Certified Professional in Healthcare Quality or case management certification.

• Successfully complete the Electronic Employment Eligibility Verification Program (E-Verify), applicable to all newly hired State employees.
• Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s 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 R2-10-207.12.) AND have an acceptable driving record for the last 39 months including no DUI, suspension or revocations and less than 8 points on your license. If an Out of State Driver License was held within the last 39 months, a copy of your MVR (Motor Vehicle Record) is required prior to driving for State Business. Employees may be required to use their own transportation as well as maintaining valid motor vehicle insurance and current Arizona vehicle registration; however, mileage will be reimbursed.

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: Driver’s 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 (pilot program).
• 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 pilot program here. 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 careers@azahcccs.gov.
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.