ALTCS Prior Authorization/Utilization Review Nurse Job Vacancy in State of Arizona Phoenix, AZ 85007 – Latest Jobs in Phoenix, AZ 85007

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Full Details :
Company Name : State of Arizona
Location : Phoenix, AZ 85007
Position : ALTCS Prior Authorization/Utilization Review Nurse

Job Description : The Division of Fee for Service Management (DFSM) is looking for a highly motivated individual to join our team as a Prior Authorization/Utilization Review Nurse. This position will review Prior Authorization request and determine medical necessity for Physical, and/or Behavioral Health Services (including Children’s Rehabilitative Services [CSR], for the Division of Developmental Disabilities (DDD) Tribal Health Plan (THP) population and approve or deny PA request.

Job Duties:

Major duties and responsibilities include but are not limited to:

Review clinical documentation, performs prospective, concurrent and retrospective reviews for medical necessity, appropriateness for admission, length of stay, level of care, quality of care, coordination of care based on State and Federal regulations, policies, and procedures governing the provision of covered services.

Collaborates with providers, Tribes, DES/DDD, and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, complex member needs, and other issues.

Provides education and technical assistance to FFS Providers, Tribal Staff, and AZDES/DDD as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies and procedures.

Evaluates, recommends action, negotiates rates, and provides on-going monitoring or program policy compliance and reporting of data related to specialty services such as Specialty DME, and Exception NF Rates.

Participates in process improvement and other special projects, work groups and committees to improve the efficiency of care coordination, utilization management and other unit functions.

Tracks and/or performs reviews for compliance related to utilization management processes and Federal and State rules and regulations related to the AHCCCS THP populations.

Devises and submits system generated reports, extracts, and analyses for unit, division, and management. Maintains documentation files.

Knowledge, Skills & Abilities (KSAs):

Knowledgeable of Principles of medical and/or behavioral management and assessment.

Knowledge of Current costs, appropriateness and utilization of medical supplies and equipment.

Knowledgeable of AHCCCS, ALTCS, Medicaid and Medicare Federal Regulations. State Statute, Rule and policies applicable to AHCCCS programs, policies and procedures.

Organizational skills for setting priorities; workload, record keeping, and prioritization of multiple tasks.

Utilization Review and Medical Claims Review skills.

Ability to evaluate medical documentation for emergency criteria, medical necessity, and correct CPT coding.

Ability to negotiate competitive rates to maximize available funding for members’ care.

Qualifications:

Professional experience in the healthcare industry, specifically experience in Prior Authorization, Concurrent Review, Retrospective.

Benefits:

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.
For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Contact Us:

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by contacting 602-417-4497. Requests should be made as early as possible to allow time to arrange the accommodation. Arizona State Government is an AA/EOE/ADA Reasonable Accommodation Employer.

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