[Hiring] Medical PA/UR & Transport Manager @Arizona Department of Administration

Role Description

Under the direction of the Clinical Administrator, responsible for the management and oversight of the DFSM Medical Prior Authorization/Utilization Review (PA/UR) and Non-Emergency Medical Transportation (NEMT), including direct supervision of unit staff. Responsibilities include operational oversight, provider relations, technology management, reporting, policy implementation, and continuous process improvement to ensure effective service delivery and compliance with program requirements.

• Provides direct management and oversight of the DFSM PA/UR Unit, Non-Emergency Medical Transportation (NEMT), and Medical Emergency Transportation programs.
• Supervises assigned staff and is responsible for hiring, training, performance management, employee development, scheduling, workload distribution, and ensuring operational coverage.
• Oversees and directs interactions with Fee-for-Service providers, including resolution of escalated provider concerns and operational issues.
• Independently assesses issues, determines appropriate resolution strategies, delegates follow-up activities, and tracks trends to support process improvement and provider engagement.
• Develops, establishes, and maintains reporting structures, performance metrics, and operational processes for the Prior Authorization, Utilization Review, and Transportation programs.
• Analyzes program data, monitors outcomes, and provides operational leadership and backup support to ensure continuity of services.
• Reviews, develops, implements, and maintains prior authorization criteria, policies, procedures, and standard work to support program compliance, consistency, and effective determination of prior authorization requirements.
• Participates in policy committees, workgroups, and related initiatives.
• Serves as the Prior Authorization subject matter expert (SME) and oversees the technological aspects of the Prior Authorization process.
• Identifies operational needs, advocates for system enhancements, and collaborates with partners to improve efficiency and effectiveness.
• As needed, provides backup for the responsibilities held by the Prior Authorization and Utilization Review staff.

Qualifications

• Possession of a current license to practice as a registered nurse in the State of Arizona OR Licensed Behavioral Health Professional.
• Four (4) years professional experience related to health programs appropriate to the assignment, which includes program planning or administration.
• Two (2) plus years of managerial experience or (2) plus years as an AHCCCS Health Care Nursing Consultant.
• A Master's degree in a field appropriate to the assignment and minimum six (6) years of experience may substitute for the license requirement.

Requirements

• Knowledge of principles and practice management and supervision.
• Knowledge of principles and practice of data research and report development.
• Knowledge of information technology processes and potential prior authorization processes.
• Knowledge of healthcare delivery systems and mechanisms for coordination and delivery of services.
• Knowledge of principles of medical and/or behavioral nursing management and assessment.
• Knowledge of current standards of medical/behavioral practice and modes of delivery for acute and non-acute medical/behavioral healthcare and services.
• Knowledge of current costs, appropriateness and utilization of medical supplies and equipment.
• Knowledge of principles of utilization review.
• Knowledge of alternative levels of care.
• Knowledge of ICD-9/10, CPT and DSM IV/V coding and medical billing guidelines.
• Knowledge of interrelations of government entities.
• Knowledge of federal and state rules, regulations, statutes and codes applicable to AHCCCS programs and populations.
• Knowledge of AHCCCS programs, policies and procedures.
• Familiarity with American Indian tribes and programs and policies relative to Intergovernmental Agreements (IGA).
• Knowledge of Prepaid Medical Management Information System (PMMIS).
• Skill in development of provider relations procedures within prior authorization/utilization review.
• Skill in interface with AHCCCS Information Services Division (ISD) to meet technological needs of Utilization Management/Care Management (UM-CM) unit.
• Skill in developing effective reporting structures and processes for UM/CM unit.
• Skill in problem solving and identification, evaluation and initiation of appropriate action, nursing assessment.
• Skill in proficiency in oral and written communications.
• Skill in public relations, interacting with statewide providers of healthcare services, public organizations, social service agencies and American Indian tribes.
• Skill in organizational skills for setting priorities, workload and record keeping.
• Skill in intermediate to advanced computer skills.
• Skill in interpreting clinical information and assessing implications for treatment.
• Skill in strong interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds.
• Ability to plan, organize and administer a healthcare program.
• Ability to teach, train and motivate direct report and others.
• Ability for independent decision making.
• Ability to represent unit, division and AHCCCS in a positive, constructive manner.
• Ability for analytical ability to identify and correlate specific patterns, initiate investigations and submit findings and recommendations.
• Ability to read, interpret and apply complex rules, regulations, statutes, policies and guidelines.
• Ability to effectively resolve provider issues with minimal disruption.
• Ability to communicate complex information in an understandable manner.

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.