Public Health Nursing Consultant

Salary: $64,575

Grade: 22

The Division of Health Care Management (DHCM) is looking for a highly motivated individual to join our team as a Public Health Nursing Consultant. After extensive training, this position has the potential of being worked from home with some in office meetings. Under the general direction of the Medical Management (MM) Manager and Supervisor, this position will monitor and evaluate Medical Management programs for the AHCCCS Complete Care Contractors, Arizona Long Term Care System and RBHA Contractors. Provide oversight of the MM process at the Contractor level. Participate in the Operational Reviews and develop, update, review and interpret policy pertaining to MM.

* 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.

* Review, research & approve transplant services for Tribal Fee-for Service members. Document in transplant database, create cases in PMMIS & send letter of approval to the transplant facilities. In the case of potential denial of services, the MM specialist will present the clinical information to the Medical Director (MD). If MD denies the request, an appropriate Notice of Action must be issued to the member & notify requesting provider

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

* Review of the annual Medical Management/Utilization Management (MM/UM) Plan, work Plan and Evaluation for each Contractor along the written communication outlining any deficiencies that need to be corrected.

* Provides oversight of transplant reinsurance for each Contractor including sending letters of approval and maintaining the reinsurance case in PMMIS.

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

* Attends Quarterly Medical Director meetings, Quarterly MM meetings and other ad hoc meetings as necessary. Participates in the Transplant Coordinators Work Group and acts as liaison between AHCCCS Contractors and transplant facilities.

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

* Nursing principles and practices

* Principles and practices of medical management

* Federal regulations, State statute, rule, policy and procedure governing the AHCCCS program.

* AHCCCS contractual agreements with Contractors

* Working knowledge of Word and Excel

* Current medical knowledge including evidence based medicine standards

* Analytical skills to interpret utilization management data

* Excellent oral and written communication skills

* Multi-task in a fast paced environment, reprioritizing as needed.

* Develop, implement and review case management and utilization review systems.

* Offer technical assistance to Acute, LTC, Sister Agency and/or Tribal Contractors

* Team player and ability to work independently.

* Communicate with all levels of professionals, corporate and agency officers and members.

* Ability to work Virtual Office

* Experience working for an AHCCCS Contractor

* Three years of clinical experience

* Ability to work independently and Utilization management skills

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.