Medical Management Specialist

The Division of Health Care Management (DHCM) is looking for a highly motivated individual to join our team as a Medical Management Specialist. This position will monitor and evaluate Medical Management programs for the AHCCCS Acute Care, Arizona Long Term Care System, and Integrated Behavioral Health Contractors. This position and Unit is additionally responsible for the technical support and oversight of the Transplant and Catastrophic Reinsurance processes. This includes transplant case management for the Fee-for Service population.

* Prepares for and participates in the Operational Reviews to include the review of pre-audit documents and policies, on-site audit, formal written documentation of findings, and monitoring the Corrective Action Plans as applicable.

* Reviews, researches and approves transplant services for the Tribal fee-for-service members which includes documentation in the transplant database, creating cases in PMMIS and sending letters of approval to the transplant facilities.

* Review catastrophic cases to ensure that AHCCCS clinical criteria for reinsurance are met. Creating reinsurance cases and providing written approval letters to each Contractor.

* Responsible to review the annual Medical Management/Utilization Management (MM/UM) Plan, Work Plan and evaluation of each Contractor along with written communication outlining any deficiencies that need to be corrected.

* Provide technical assistance to the Contractors as needed relating to MM policies, transplant activities or catastrophic reinsurance.

* Assists in the review and revision of MM policies and procedures as needed.

* Active/Current Arizona RN license.

* Principles and practices of medical management; nursing principles and practices.

* Excellent oral and written communication skills; ability to communicate with all levels of professionals, corporate and agency officers and members.

* Ability to multi-task in a fast-paced environment, reprioritizing as needed.

* Demonstrated experience using Microsoft Office Products: Word and Excel.

* Team player and ability to work independently.

* One-two years experience working for an AHCCCS contractor

* Three years of clinical experience

* Utilization management skills

* One-two years behavioral health experience

In accordance with CFR 432.50 FFP, skilled professional medical personnel must have professional education and training in the field of medical care or appropriate medical practice. 'Professional education and training" means the completion of a 2-year or longer program leading to an academic degree or certification in a medically related profession. For this position, a licensed Registered Nurse, Physician's Assistant or Nurse's Practitioner is required. Experience in the administration, direction, or implementation of the Medicaid program is not considered the equivalent of professional training in a field of medical care.

At AHCCCS, we promote the importance of work/life balance by offering workplace flexibility and a variety of learning and career development opportunities. Among the many benefits of a career with the State of Arizona, there are 10 paid holidays per year, accrual of sick and annual leave, affordable medical benefits and participation in the Arizona State Retirement Plan.

For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by contacting 602-417-4497.
Requests should be made as early as possible to allow time to arrange the accommodation. Arizona State Government is an AA/EOE/ADA Reasonable Accommodation Employer.