Behavioral Health Prior Authorization Utilization Review Consultant

AHCCCS; Phoenix (AZ); Hybrid; USD 70,000 - 100,000; Full time

Job summary

AHCCCS in Phoenix seeks an Behavioral Health Prior Authorization Utilization Review Consultant to monitor, evaluate, and decide on payment for medical and behavioral services under AHCCCS Fee for Service.

The role requires licensing, clinical expertise, and strong analysis to ensure compliance with standards of care and regulations, with collaboration across providers and staff and education to support utilization management.

Qualifications

• Current Arizona medical license (RN or higher) or Arizona Behavioral Health license with at least 3 years of healthcare experience.
• Knowledge of ICD-9/10, DSM-IV/V, and CPT coding and usage.
• Strong analytical, data interpretation, and communication skills.

Responsibilities

• Monitor and approve or deny payment for medical and behavioral services based on standards.
• Collaborate with providers and staff on care coordination and utilization review.
• Provide education and technical assistance to ensure AHCCCS compliance.

Skills

Healthcare licensing knowledge

Analytical reasoning

Communication skills

Data interpretation

Problem-solving

Education

Arizona medical license or Behavioral Health license

Tools

ICD-9/10 coding

DSM-IV/V

CPT coding

Job description

The Behavioral Health Prior Authorization Utilization Review Consultant monitors, evaluates, and approves or denies payment for medical and behavioral healthcare services through prospective, concurrent, and retrospective review for Arizona's Medicaid (AHCCCS) Fee for Service population. The role determines medical necessity based on standards of care and regulations, collaborates with providers and staff on care coordination and utilization review, and provides education and technical assistance to ensure compliance with AHCCCS requirements. This position is located in Phoenix with remote work options available and is part of the Division of Fee for Service Management.

Key qualifications:

• Current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and 3 years of relevant healthcare experience
• Knowledge of healthcare delivery systems, medical/behavioral management principles, and utilization review
• Proficiency in ICD-9/10 diagnosis coding, DSM-IV/V, and CPT procedure coding
• Strong analytical and problem-solving skills with ability to identify patterns and correlate data
• Excellent interpersonal and oral/written communication skills
• Experience in Prior Authorization, Utilization Management, claims review, or managed care (preferred)