Senior Behavioral Health Utilization Review Consultant

State of Arizona; Phoenix (AZ); Hybrid; USD 64,000 - 78,000; Full time

Benefits offered by this job

Remote work opportunities within AZ

Flexible work arrangements

Paid holidays

Job summary

AHCCCS in Arizona is seeking a Behavioral Health Prior Authorization Utilization Review Consultant to monitor, evaluate, and approve or deny payment for behavioral health services within the Fee for Service population. The role requires verifying medical necessity according to standards of care, rules, and AHCCCS policies.

Responsibilities include collaboration with providers, staff, and tribal entities, monitoring program policy compliance, and generating reports to support utilization

Qualifications

• Understanding 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.
• Principles of utilization review.
• ICD-9/10 Diagnosis Coding; DSM-IV/V; CPT procedure coding.
• Interrelations of governmental agencies.
• AHCCCS/ALTCS/Medicaid/Medicare Federal Regulations.

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.
• Confers with Utilization Review Coordinators regarding concurrent review of length of stay and appropriateness of services.
• Provides education and technical assistance to FFS Providers and Tribal staff 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 related to AHCCCS FFS populations.
• Devises and submits system generated reports, extracts, and analyses for unit and division management.
• Participates in process improvement and other special projects, work groups, and committees.

Job description

AHCCCS in Arizona is seeking a Behavioral Health Prior Authorization Utilization Review Consultant to monitor, evaluate, and approve or deny payment for behavioral health services within the Fee for Service population. The role requires verifying medical necessity according to standards of care, rules, and AHCCCS policies.

Responsibilities include collaboration with providers, staff, and tribal entities, monitoring program policy compliance, and generating reports to support utilization