Arizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Teamwork
Medical Management Specialist
First Resume Review: 09/03/2019
Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid Agency, is driven by the passion to deliver comprehensive and cost effective health care to Arizonans in need. AHCCCS is nationally acclaimed as a model for other Medicaid programs and recipient of multiple awards for excellence in workplace effectiveness and flexibility.
All Arizona state employees operate within the Arizona Management System (AMS), an intentional, results-driven approach for doing the work of state government whereby every employee reflects on performance, reduces waste, and commits to continuous improvement with sustainable progress. Through AMS, every state employee seeks to understand customer needs, identify problems, improve processes, and measure results. State employees are highly engaged, collaborative and embrace a culture of public service. Visit our careers page to learn more about AHCCCS. Use your skills to benefit others; join the AHCCCS Team!
The Division of Health Care Management (DHCM) is looking for a highly motivated individual to join our team as a Public Health Nursing Consultant. Under the general direction of the Medical Management 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 Reviews and develop, update, review and interpret policy pertaining to MM. Major duties and responsibilities include but are not limited to:
* Prepares for and participates in the Operational Reviews 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.
* Reviews, researches and approves transplant services for the Tribal Fee-for Service members which includes documentation on the transplant database, creating cases in PMMIS and sending letters 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. If the Medical Director denies the request, an appropriate Notice of Action must be written and sent to the member as well as notifying the requesting provider.
* Reviewing catastrophic cases to ensure that AHCCCS clinical criteria for reinsurance are met. Creating reinsurance cases and providing written approval letters to each Contractor.
* Review of the annual Medical Management/Utilization Management (MM/UM) Plan, work Plan and Evaluation for each Contractor along the written communication outlining any deficiencies that need to be corrected.
* Provides oversight of transplant reinsurance for each Contractor including sending letters of approval and maintaining the reinsurance case in PMMIS.
* Provides technical assistance to the Contractors as needed relating the MM policies, transplant activities or catastrophic reinsurance.
* Attends Quarterly Medical Director meetings, 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.
KNOWLEDGE, SKILLS AND ABILITIES (KSAs):
* Principle and Practices of Nursing and Medical Management
* AHCCCS contractual agreements with Contractors
* Federal regulations, State statute, rule, policy and procedure governing the AHCCCS program.
* Develop, implement and review case management and utilization review systems
* Analytical skills to interpret utilization management data
* Current medical knowledge including evidence based medicine standards
* Excellent oral and written communication skills
* A licensed Registered Nurse, Physician's Assistant or Nurse's Practitioner is required. Experience in the administration, direction, or implementation of the Medicaid program is not considered the equivalent of a professional training in a field of medical care.
* Two-three years experience working in a managed care environment
* Three years of clinical experience
* Ability to work independently and Utilization management skills
At AHCCCS, we promote the importance of work/life balance by offering workplace flexibility and a variety of learning and career development opportunities. Among the many benefits of a career with the State of Arizona, there are 10 paid holidays per year, accrual of sick and annual leave, affordable medical benefits and participation in the Arizona State Retirement Plan. Click here to learn more about benefits.
Arizona State Government is an EOE/ADA Reasonable Accommodation Employer. Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by calling (602) 417-4497. Requests should be made as early as possible to allow sufficient time to arrange the accommodation. AHCCCS is an Equal Employment Opportunity Employer. All newly hired employees will be subject to E-Verify Employment Eligibility Verification.
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For technical assistance, email HRIShelpdesk@azdoa.gov or call 602-542-4700.