Quality Management Nursing Consultant

State of Arizona; Phoenix (AZ); Hybrid; USD 60,000 - 82,000; Full time

Job summary

AHCCCS, Arizona’s Medicaid agency, seeks a Quality Management Nursing Consultant to assess and monitor service delivery, review provider resources, and ensure compliance with state and federal regulations. The role combines independent clinical judgment with collaboration across teams.

The position is hybrid, involves on-site investigations at least 20% of the time, and offers meaningful opportunities to address systemic issues and improve member care within AHCCCS guidelines.

Qualifications

• Knowledge of state and federal policies governing Medicaid and managed care.
• Clinical nursing knowledge and judgment.
• Utilization review and case management expertise.

Responsibilities

• Monitor compliance with state and federal regulations; track and resolve quality and safety issues.
• Provide clinical input for quality reviews and policy compliance.
• Conduct on-site investigations of health and safety concerns.
• Ensure quality of care and respect for member dignity.
• Lead process improvements and special projects with timely updates to management.
• Develop population-specific outcome metrics and analyze member data.
• Educate internal/external stakeholders on covered services and policy requirements.

Skills

Quality management

Clinical assessment

Utilization review

Policy knowledge

Case management

Education

Bachelor's in Nursing

Job description

AHCCCS

Arizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork
The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility.
AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry.
Come join our dynamic and dedicated team.

Quality Management Nursing Consultant

Division of Fee for Service Management (DFSM)

Job Location:

Phoenix - 150 North 18th Avenue Phoenix, Arizona 85007
Tucson - 4760 South Park Avenue Tucson, Arizona 85714

Posting Details:

Starting salary 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 will work independently applying clinical knowledge, judgment, and expertise to assess, coordinate, and monitor service delivery. This position will complete comprehensive assessments of available resources on service providers and individual members; review case material to ensure compliance with State and Federal regulations and policies; and provide timely resolution of multiple cases assigned. This position will also be responsible for identifying systemic issues for AHCCCS to address.

This position will be hybrid with some in-office meetings, on-site investigations at least 20% of your time, and reviews as needed. Occasionally, this position may also participate as needed in urgent on-site investigations and reviews outside of normal business hours and weekends.

Major duties and responsibilities include but are not limited to:

• Monitor compliance with State and Federal regulations pertaining to quality management processes, tracking, and trending quality of care concerns and/or health and safety/immediate jeopardy concerns. Receive, research, document, and resolve quality of care and/or health and safety issues utilizing standardized processes. Track, trend, and monitor the status of cases to ensure accurate and timely completion and appropriate referrals using a centralized case management tracking database. Ensure research and resolution of issues or concerns promptly as assigned and identify systemic issues for AHCCCS to address.
• Contributes clinical knowledge to assist in the resolution of quality of care concerns, clinical reviews and Operational Reviews. Completes an independent review of data management and other deliverables, technical assistance, and focused studies/reviews, including the behavioral health delivery system, to ensure compliance with contractual and policy requirements for all lines of business. Follow-up on written reports, action plans, provider education and related actions as appropriate.
• Conduct on-site investigations regarding possible health and safety concerns, immediate jeopardy situations, and other situations supporting AHCCCS initiatives and ventures. On-site visits may also occur outside of normal business hours and weekends for immediate and urgent situations.
• Ensure quality of care to AHCCCS members, including ensuring member dignity and respect, focused on their unique special health care needs, timely correspondence, and resolution of the quality of care concern. Use independent judgment regarding data to research, status level, interventions, and appropriate resolution.
• Develop improved processes and procedures to improve the efficiency of the unit. Lead special projects and reviews to ensure completion within the designated timelines. Provide ongoing updates to Management.
• Develop metrics for population-specific outcome objectives. Tracking, evaluation, analysis, and revision of metrics as needed based on the ongoing analysis of member data.
• Provide education and technical assistance to internal and external stakeholders, as appropriate, regarding covered services, and contractual or policy requirements, accurately and consistently to improve compliance with AHCCCS requirements and improve quality of care and service to AHCCCS members.

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, and LTC Supports and Services
• Current standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care/services
• Data management and utilization review regulations, rules and processes
• AHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules
• Medical/nursing practice, medical case management protocols, utilization review protocols as related to the acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, and behavioral/mental health
• Case management development, implementation, and ongoing review

Skill in:

• Acute nursing and clinical processes including assessment, planning, intervention, and evaluation
• Clinical assessment skill
• Techniques to select a particular approach to analyze develop or implement a policy, project management methodologies, and Behavioral Health delivery system
• Problem-solving techniques, evaluation, and