Informatics & Prepayment Review Health Consultant
Division of Fee for Service Management (DFSM)
Job Location:
Address: 150 N. 18th Avenue Phoenix, AZ 85007
This position offers the opportunity for full-time remote work. However, based on business needs, occasional in-office attendance or in-person customer visits may be required.
Posting Details:
Salary starting at $71,032 and may be increased based on experience and qualifications.
FLSA Status: Exempt
Grade: 22
Closing Date: Open until filled
Job Summary:
This position reports directly to Claims Operations Administrator. This position will work independently applying clinical knowledge, judgment, and expertise to assess, coordinate, and monitor service delivery with project components. The position will complete comprehensive data analytics and is responsible for interdisciplinary collaboration representing the division (DFSM) as the data subject matter expert (SME) as it related to quality and program integrity. This position assists with compliance and monitoring functions, running data reports including analyzing the data, clinical significance and recommendations on next steps. This position will also be responsible for identifying systemic issues for AHCCCS to address. This position works collaboratively with the prepayment review and audit teams to help ensure prepayment reviews of clinical documents are completed in a timely manner.
Major duties and responsibilities include but are not limited to:
• Perform prepayment review of behavioral health documents submitted in support of behavioral health claims. Including responses to disputes of behavioral health claims.
• Identify trends, issues, outliers which may need to be addressed by DFSM and/or other leaders. Succinctly and clearly summarizes data issues and trends in writing and verbally. Makes direct referrals to OIG, QM and PPR teams as appropriate based on findings.
• Responsible for creating reports and presentations which synthesize information and explain the clinical significance as well as the rationale of findings and recommendations.
• Serve as a DFSM Informatics SME, overseeing all the data for the division, including ODA analytics reports submitted for review to the division. Develop reports in Cognos which can be easily run ad hoc by staff. Including providing technical assistance and training to staff in use of Cognos. Set up special handling's in PMMIS and Alivia.
• Responsible for data analysis project management; creating and maintaining reports & meetings as necessary. Follow-up on written reports, action plans, escalations, education, and other actions as appropriate. Focus on continuous process improvement related to Data and Reporting processes leading projects as needed.
• Provides education, technical assistance to internal and external stakeholders, and participates in various cross agency meetings serving as subject matter expert of the data for the division. Share reports and updates regularly with leadership based on data analysis.
The State of Arizona strives for a work culture that affords employees flexibility, autonomy, and trust. Across our many agencies, boards, and commissions, many State employees participate in the State’s Remote Work Program and are able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona unless an exception is properly authorized in advance.
Knowledge, Skills & Abilities (KSAs):
Knowledge of:
• State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, Behavioral Health, LTC and Tribal and Children’s Rehabilitative Services
• Clinical experience in various medical/ behavioral health settings including understanding of the technology and information
• Current standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care services
• Data analysis, data management and utilization review regulations, rules and processes and interpretation
• AHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules
• Structure and operation of the Arizona behavioral health system
Skills in:
• Advanced skills in Microsoft Office (SharePoint, Excel, Access) and Google suite
• Problem-solving techniques, evaluation, and initiation of appropriate action
• Excellent communication, verbal and written skills
• Organizational skills for setting priorities, workload, and record-keeping
• Strong interpersonal skills in working with agency management, cross divisional, and interdisciplinary groups including people of diverse cultures and socioeconomic backgrounds
• Project management skills including system implementation, process improvement and ability to meet goals and deadlines
• Research and analytical skills
• Documentation and reporting of data and trends with clinical significance
• Behavioral Health processes including assessment, treatment planning, intervention, and evaluation
• Acute nursing and clinical processes including assessment, planning, intervention, and evaluation
Ability to:
• Explain complex data in a succinct and clear manner that people can understand
• Understand complex data reports
• Read and interpret a spreadsheet
• Write comprehensive reports such as data driven decision making and quality improvement to enhance outcomes
• Read, interpret and apply complex rules and regulations
• Adapt to new technology and programs assisting with data analysis and inference/ applicability to other areas
Selective Preference(s):
Minimum: Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and 3 years of relevant healthcare experience. May require a valid Arizona Driver License for travel-related duties.
Preferred: Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served. Experience in outpatient behavioral health services. Preferred skills in power BI.
Pre-Employment 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 (see Arizona Administrative Code R2-10-207.12.)
If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements.
All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
Benefits:
Among the many benefits of a career with the State of Arizona, there are:
• 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. Learn more about the Paid Parental Leave pilot program here.
• 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
By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.
Learn more about the Paid Parental Leave program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page
Retirement:
Lifetime Pension Benefit Program
• Administered through the Arizona State Retirement System (ASRS)
• Defined benefit plan that provides for life-long income upon retirement.
• Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.
• Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).
Deferred Retirement Compensation Program
• Voluntary participation.
• Program administered through Nationwide.
• Tax-deferred retirement investments through payroll deductions.
Contact Us:
Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.
Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.
