The Division of Fee for Service Management is looking for a highly motivated individual to join our team as an Arizona Long Term Care System (ALTCS) Nurse. This position is responsible for monitoring, evaluating, and approving/denying the medical payment of medical and/or behavioral health (BH) services through prospective, concurrent, and retrospective review for the AHCCCS ALTCS Fee for Service populations. It is accountable for the prevention and/or resolution of utilization problems adversely affecting the balance between quality of care, cost effectiveness, and minimization of risk through the use of the utilization management review process.
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 and policies and procedures governing the provision of covered services.
● 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.
● Monitors specialized programs such as Home Modifications and approvals for participation of payment and reporting of member data. 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.
● 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, Exception NF Rates and over Institutional cost 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 reviews for compliance related to utilization management process and Federal and State rules and regulations related to FFS populations. Devises and submits system generated reports, extracts, and analyses to unit and division management. Maintains documentation files.
● Understanding of healthcare delivery system, mechanisms necessary for coordination and delivery of services.
● Principles of medical and/or behavioral management and assessment.
● Current standards of medical and/or behavioral practice, delivery of medical/behavioral care.
● Knowledge of HCPCS codes Levels I & II and, knowledge of International Classification of Diseases, DSM IV/V coding and medical billing guidelines.
● Medical and psycho-social needs of ALTCS members cultural, environmental and community influences on behavior of ALTCS members.
● Problem solving-identification, evaluation, initiation of appropriate action, nursing assessment.
● Proficiency in oral and written communication.
● Public relations skills, interacting with statewide providers of healthcare services public organizations and social agencies.
● Organizational skills for setting priorities, workload and record keeping.
● Analytical ability to identify and correlate specific patterns, initiate investigations, submit findings and recommendations.
● Interpret clinical information and assess implications for treatment.
● Negotiate competitive rates to maximize available funding for member’s care.
● Read, interpret, and apply complex rules & regulations.
● Independent decision making.
● Implement AHCCCS & ALTCS program design, including case management functions and responsibilities, provider network, and funding source.
● Current Arizona Registered Nurse License.
● Experience Working Virtually, Professional experience in the Healthcare Industry “Specifically experience in Prior Authorization, Concurrent Review, Retrospective Review, and Utilization Management”.
• 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 is 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 then 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.
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 (12 and 13 days per year respectively) - start earning it your 1st day (prorated for part-time employees)
• 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
• Opportunity to work 100% virtually or remotely on an ad-hoc basis (home office)
By providing the option of a full-time or part-time virtual/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.
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 firstname.lastname@example.org.
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.