[Hiring] Public Healthcare Consultant @Arizona Department of Administration

Role Description

Under the general direction of the Medical Management (MM) Manager and Supervisor, this position will monitor and evaluate Medical Management programs for the AHCCCS Complete Care Contractors, Arizona Long Term Care System and RBHA Contractors. Provide oversight of the MM process at the Contractor level. Participate in the Operational Review and develop, update, review and interpret policy pertaining to MM.

• Prepares for and participates in audits to include the review of pre-audit documents and policies, on-site audit, formal written documentation of findings and monitoring the corrective Action Plans as applicable.
• Provides oversight of transplant reinsurance for each Contractor including sending letters of approval and maintaining the reinsurance case in PMMIS. Provide assistance to DFSM for approval for Tribal Fee-For-Service members. Document in transplant database, create cases in PMMIS & send letter of approval to the transplant facilities. In the case of potential denial of services, the MM specialist will present the clinical information to the Medical Director (MD). If MD denies the request, an appropriate Notice of Action must be issued to the member & notify requesting provider.
• Reviewing catastrophic cases to ensure that AHCCCS clinical criteria for reinsurance are met. Creating reinsurance cases and providing written approval letters to Contractor.
• Review of all MM contractual deliverables including the annual Medical Management/Utilization Management (MM/UM) Plan, work plan and Evaluation for each Contractor along with written communication outlining any deficiencies that need to be corrected.
• Review, research, develop issue paper on assigned topic, and present to the AHCCCS Technology and Services Committee.
• Provides technical assistance to the Contractors as needed relating to the MM policies, transplant activities or catastrophic reinsurance. Address member concerns and document activity within database.
• Attends Quarterly MM meetings and other ad hoc meetings as necessary. Participates in the Transplant Coordinators Work Group and acts as liaison between AHCCCS Contractors and transplant facilities.
• Assists in the review and revision of MM policies as needed.

Qualifications

• May require a valid Arizona driver’s license for travel-related duties.
• Minimum: Must maintain a current Arizona medical license (RN or higher), and 3 years of relevant healthcare experience.
• Preferred: Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served.

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 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.
• 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
• Remote work options available for improved work/life balance.