Behavioral Health Prior Authorization Consultant (Remote)

Arizona Department of Administration; United States; Remote; USD 64,000 - 78,000; Full time

Benefits offered by this job

Paid holidays

Vacation and sick leave

Paid parental leave

Retirement plan

Health insurance

RideShare subsidy

Job summary

AHCCCS in Arizona is seeking a Behavioral Health Prior Authorization Utilization Review Consultant to monitor, evaluate, and approve or deny payments for medical and behavioral services in the Fee for Service population. You will determine medical necessity based on standards, rules, and AHCCCS policies, ensuring high-quality, cost-effective care.

Responsibilities include collaboration with providers and tribal staff, ongoing monitoring for policy compliance, and preparing system-generated

Qualifications

• Knowledge of health care delivery systems and mechanisms necessary for coordination and delivery of services
• Principles of medical and/or behavioral management and assessment
• Current standards of medical/behavioral practice and delivery of acute/non-acute medical/behavioral care
• Current costs, appropriateness and utilization of medical supplies and equipment
• Principles of utilization review
• ICD-9/10 Diagnosis Coding; DSM-IV/V; CPT procedure coding
• Medical technology computer data retrieval and input
• Interrelations of governmental agencies
• AHCCCS, ALTCS, Medicaid and Medicare Federal Regulations. State Statute and Rule and policies applicable to AHCCCS programs, policies and procedures
• Code of Federal Regulation (42 CFR)
• Medical and psycho- social needs of ALTCS members, cultural, environmental, and community influences on behavior of ALTCS members
• AHCCCS and ALTCS program design and implementation, including case management functions and responsibilities, provider network, and funding source
• Familiarity with American Indian Tribes/ programs and policy relative to IGA's and other related policies

Responsibilities

• Collaborates with providers, Tribal and AHCCCS staff regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs, and other issues
• Evaluates, recommends action, negotiates rates, and provides ongoing monitoring for program policy compliance and reporting of data related to specialty services such as Specialty DME, Exception NF Rates, and Over Institutional Cost services
• Confers with Utilization Review Coordinators from the Peer Review Organization regarding concurrent review of length of stay and appropriateness of services
• Provides education and technical assistance to FFS Providers and Tribal staff as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies, and procedures
• Tracks and/or performs focused reviews for compliance related to utilization management processes and Federal and State Rules and Regulations related to the AHCCCS FFS populations. Maintain documentation files
• Devises and submits system generated reports, extracts, and analyses for unit and division and management
• Participates in process improvement and other special projects, work groups, and committees to improve the efficiency of care coordination, utilization management, and other functions in the Clinical Administration unit

Job description

AHCCCS in Arizona is seeking a Behavioral Health Prior Authorization Utilization Review Consultant to monitor, evaluate, and approve or deny payments for medical and behavioral services in the Fee for Service population. You will determine medical necessity based on standards, rules, and AHCCCS policies, ensuring high-quality, cost-effective care.

Responsibilities include collaboration with providers and tribal staff, ongoing monitoring for policy compliance, and preparing system-generated