[Hiring] Behavioral Health Prior Authorization Utilization Review Consultant @Arizona Department of Administration

Role Description

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.

Qualifications

• Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and 3 years of relevant healthcare experience.
• Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served preferred.

Requirements

• 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.
• All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Benefits

• 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.
• 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