Arizona State Government
Public Health Nursing Consultant
Arizona State Government, Baltimore, Maryland, United States
AHCCCS
The Arizona Health Care Cost Containment System (AHCCCS) is Arizona’s Medicaid agency. AHCCCS is a nationally acclaimed model among Medicaid programs and offers meaningful career opportunities in a competitive industry. All AHCCCS employees must reside within the state of Arizona.
Public Health Nursing Consultant Division of Managed Care (DMC)
Job Location : Address: 150 North 18th Avenue, Phoenix, Arizona 85007
All AHCCCS Employees must reside within the state of Arizona.
Salary : $71,032
FLSA Status : Exempt
Grade : 22
Position Status : Will remain open until filled.
Job Summary 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.
Major duties and responsibilities
Prepare for and participate in audits, including review of pre-audit documents and policies, on-site audits, formal written findings, and monitoring corrective action plans as applicable.
Provide oversight of transplant reinsurance for each Contractor, including sending letters of approval and maintaining cases in PMMIS. Assist DFSM for approval for Tribal Fee-For-Service members. Document in transplant database, create cases in PMMIS, and issue notices as needed. Present clinical information to the Medical Director for potential denials and issue a Notice of Action if denied.
Review catastrophic cases to ensure AHCCCS clinical criteria for reinsurance are met; create reinsurance cases and provide written approval letters to Contractors.
Review all MM contractual deliverables (e.g., MM/UM Plan, work plan, evaluations) and communicate deficiencies to be corrected.
Research, develop issue papers on assigned topics, and present to the AHCCCS Technology and Services Committee.
Provide technical assistance to Contractors on MM policies, transplant activities, or catastrophic reinsurance. Address member concerns and document activity.
Attend Quarterly MM meetings and other ad hoc meetings. Participate in the Transplant Coordinators Work Group and act as liaison between AHCCCS Contractors and transplant facilities.
Assist in the review and revision of MM policies as needed.
Knowledge, Skills & Abilities (KSAs) Knowledge : Nursing principles and practices; medical management principles and practices; federal regulations, state statutes, rules, policies governing the AHCCCS program; AHCCCS contractual agreements with Contractors; basic computer knowledge; working knowledge of Word and Excel; current medical knowledge including evidence-based medicine standards.
Skills : Analytical skills to interpret utilization management data; excellent oral and written communication; effective interpersonal skills; critical thinking.
Abilities : Multi-task in a fast-paced environment and re-prioritize as needed; develop, implement and review case management and utilization review systems; provide technical assistance to Acute, LTC, other state agencies and Tribal Contractors; work independently and with a team; communicate with all levels of professionals and agency staff.
Qualifications Arizona Driver's License
Minimum : A licensed Registered Nurse, Physician's Assistant or Nurse's Practitioner is required and three (3) years of relevant clinical experience. Experience in administration, direction, or implementation of the Medicaid program is not considered equivalent professional training.
Preferred : Experience working as an AHCCCS Contractor; experience working independently and applying utilization management skills.
Pre-Employment Requirements
Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above process and the agency’s ability to reasonably accommodate restrictions.
Travel may be required for State business. A valid driver record and compliance with driver training requirements are required for state business driving. Mileage may be reimbursed.
All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
Benefits and Retirement Benefits : 10 paid holidays, paid vacation and sick leave, parental leave, other leaves (bereavement, civic duty, military), retirement program with lifetime pension benefits, health/dental/life/disability insurance, Public Service Loan Forgiveness eligibility, RideShare and transit subsidies, and career development opportunities. Remote work options may be available but are not guaranteed.
Retirement : Lifetime Pension Benefit through the Arizona State Retirement System (ASRS); Deferred Retirement Compensation option.
Contact Persons with a disability may request accommodations by emailing careers@azahcccs.gov. Requests should be made early to arrange accommodations. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.
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Public Health Nursing Consultant Division of Managed Care (DMC)
Job Location : Address: 150 North 18th Avenue, Phoenix, Arizona 85007
All AHCCCS Employees must reside within the state of Arizona.
Salary : $71,032
FLSA Status : Exempt
Grade : 22
Position Status : Will remain open until filled.
Job Summary 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.
Major duties and responsibilities
Prepare for and participate in audits, including review of pre-audit documents and policies, on-site audits, formal written findings, and monitoring corrective action plans as applicable.
Provide oversight of transplant reinsurance for each Contractor, including sending letters of approval and maintaining cases in PMMIS. Assist DFSM for approval for Tribal Fee-For-Service members. Document in transplant database, create cases in PMMIS, and issue notices as needed. Present clinical information to the Medical Director for potential denials and issue a Notice of Action if denied.
Review catastrophic cases to ensure AHCCCS clinical criteria for reinsurance are met; create reinsurance cases and provide written approval letters to Contractors.
Review all MM contractual deliverables (e.g., MM/UM Plan, work plan, evaluations) and communicate deficiencies to be corrected.
Research, develop issue papers on assigned topics, and present to the AHCCCS Technology and Services Committee.
Provide technical assistance to Contractors on MM policies, transplant activities, or catastrophic reinsurance. Address member concerns and document activity.
Attend Quarterly MM meetings and other ad hoc meetings. Participate in the Transplant Coordinators Work Group and act as liaison between AHCCCS Contractors and transplant facilities.
Assist in the review and revision of MM policies as needed.
Knowledge, Skills & Abilities (KSAs) Knowledge : Nursing principles and practices; medical management principles and practices; federal regulations, state statutes, rules, policies governing the AHCCCS program; AHCCCS contractual agreements with Contractors; basic computer knowledge; working knowledge of Word and Excel; current medical knowledge including evidence-based medicine standards.
Skills : Analytical skills to interpret utilization management data; excellent oral and written communication; effective interpersonal skills; critical thinking.
Abilities : Multi-task in a fast-paced environment and re-prioritize as needed; develop, implement and review case management and utilization review systems; provide technical assistance to Acute, LTC, other state agencies and Tribal Contractors; work independently and with a team; communicate with all levels of professionals and agency staff.
Qualifications Arizona Driver's License
Minimum : A licensed Registered Nurse, Physician's Assistant or Nurse's Practitioner is required and three (3) years of relevant clinical experience. Experience in administration, direction, or implementation of the Medicaid program is not considered equivalent professional training.
Preferred : Experience working as an AHCCCS Contractor; experience working independently and applying utilization management skills.
Pre-Employment Requirements
Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above process and the agency’s ability to reasonably accommodate restrictions.
Travel may be required for State business. A valid driver record and compliance with driver training requirements are required for state business driving. Mileage may be reimbursed.
All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
Benefits and Retirement Benefits : 10 paid holidays, paid vacation and sick leave, parental leave, other leaves (bereavement, civic duty, military), retirement program with lifetime pension benefits, health/dental/life/disability insurance, Public Service Loan Forgiveness eligibility, RideShare and transit subsidies, and career development opportunities. Remote work options may be available but are not guaranteed.
Retirement : Lifetime Pension Benefit through the Arizona State Retirement System (ASRS); Deferred Retirement Compensation option.
Contact Persons with a disability may request accommodations by emailing careers@azahcccs.gov. Requests should be made early to arrange accommodations. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.
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