Division of Healthcare Management

Clinical Resolution Unit  

Responsible for triaging calls and inquiries, providing information about the scope and delivery of behavioral health services, eligibility for services as a person with Serious Mental Illness (SMI), and accessing treatment for substance use disorders. Designated contact for issues involving Jacob’s Law (timely access to behavioral health services for children/youth in foster care and adoptive families) and responsible for overseeing SMI Opt-Out and decertification processes. Coordinates with members, stakeholders, AHCCCS Contractors and other AHCCCS units on issues involving integrated physical and behavioral health service delivery and provides oversight and monitoring of Contractor resolution of issues and complaints as required by regulation and policy.

Clinical Quality Management  

Responsible for all quality management and oversight functions for all member populations. Monitor, measure, report and identify activities and opportunities to improve Contractor clinical and non-clinical performance rates. Ensure moms and babies receive all recommended care and services under EPSDT and appropriate prenatal care. Oversee and monitor clinical quality management investigations according to patient safety indicators which includes implementation of process improvements and interventions to correct identified gaps in care or provider/facility trends. Oversee the Contractor's clinical quality management Operational Review functions, Annual Plans as well as other key deliverables in accordance with AHCCCS AM PM policy.

Finance & Reinsurance  

Oversees the financial condition of all Contractors via review of quarterly and annual financial reports, performance bonds and other viability ratios. Reviews Value Based Contracting processes and compensation of the Contractors. Analyzes, audits and processes reinsurance payments to Contractors. Prepares various financial and enrollment reports for AHCCCS leadership and public posting on the AHCCCS website.

Operations  

Establishes fee-for-service reimbursement rates for over 80,000 clinical services [UA1] annually. Calculates supplemental payments to Arizona hospitals annually. Reconciles payments made to Federally Qualified/Rural Health Clinics and calculates the rates these clinics are paid. Reviews and adjusts payment methodologies periodically to improve cost-effectiveness and equity. Calculates nursing facility assessment and hospital assessment payments. Calculates and reconciles tribal case management rates. Provides a number of annual reports to the Legislature regarding Arizona hospitals. Perform financial oversight and monitoring of expenditures for the Medicaid Promoting Interoperability (PI) Program and Targeted Investment Program.