AHCCCSArizona Health Care Cost Containment System
|
| Job Location: |
| Posting Details: |
| Job Summary: |
The Team Lead will ensure and provide direct oversight to each BH Clinical Review Team member to verify their clinical reviewer competencies in the following areas: Utilizing standard work procedures to complete clinical reviews of behavioral health records and claims. Meet on-going competencies and training metrics for accurate use of PMMIS/Claims Processing Software, EDMS, Service Now, and Microsoft applications. Collaborate with PPR Program Manager and DFSM policy subject matter experts to assist reviewers with maintaining current knowledge of State, Federal, and AHCCCS laws, policies, and practices as applicable to behavioral health. Assist PPR Program Manager with new hires of BH reviewers including but not limited to: pre-screening, interviewing, on-boarding, and on-going training/clinical oversight.
Under the guidance of the Pre-Payment Review Program Manager, the team lead will assist and co-facilitate internal team meetings and by-weekly individual oversight sessions. The team lead will assist with BH reviewer goal setting and on-going support to meet monthly/quarterly objectives including cross-training in various domains outside of the behavioral health clinical reviews.
The team lead will engage in on-going monitoring and support of BH reviewer work-related stressors, clinical and technical challenges/questions, and work to mitigate daily needs and concerns. The Team Lead will work closely with PPR Program Manager, Claims Operations Manager, and Clinical Consultants/SME’s to identify and resolve immediate or systemic complications associated with the BH clinical review processes.
Under the guidance of the Pre-Payment Review Program Manager, the team lead will assist with behavioral health provider Technical/Clinical Assistance meetings that aim to support providers with their compliance of contractual, regulatory, and statutory obligations for Fee-for-Service (FFS) members. The Team Lead will assist with submissions of OIG referrals for suspected fraud, waste, and abuse. The Team Lead will assist with evaluating and monitoring trends in over and underutilization of covered services/codes billed. Contribute to evaluating and organizing claims and clinical information from multiple sources, including utilization data, case file reviews, and formal clinical audits.
The 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.
Major duties and responsibilities include but are not limited to:
• Will assist to ensure each team member is performing to the highest level and accordance to the direction of the Prepayment Review Program Manager, Claims Administrator and DFSM Leadership.
• Meet with the Prepayment Review Program Manager and/or other team leads and/or supervisors to discuss overall unit objectives and individual staff metrics, and to develop a fluid management plan that contains the action steps on how, as a management team, we can succeed on all assigned tasks and leadership's expectations.
• Assist in facilitating assigned team meetings, huddle boards and similar meetings. Encourage staff to participate in these meetings so innovative ideas can be discussed and implemented, to improve overall team metrics.
• Participate in the development and delivery of trainings relating to the improvement of the overall BH pre-payment claims review process, audit and related areas.
• Participate in internal and external meetings as requested and collaborate with other DFSM Claims staff to ensure full understanding of team and departmental work flows.
• Become efficient in utilizing the Arizona Health Care Cost Containment System (AHCCCS) information system called Prepaid Medical Management Information System (PMMIS), in order to process pre-payment reviewed claims and have the ability to train staff on this integral system.
| Knowledge, Skills & Abilities (KSAs): |
Knowledge:
• Service Authorization concepts, principles, and strategies
• Advanced knowledge of the behavioral health service delivery system and the needs of children and the needs of individuals designated as SMI
• Principles of behavioral health management and assessment
• Individual service planning process and substance abuse treatment
• HCPCS codes Levels I & II and, knowledge of International Classification of Diseases, DSM IV/V coding and medical billing guidelines
• Medical technology, computer data retrieval and input, including EHR, HIE, etc
• Medicaid and Medicare Federal Regulations, State Statute, Rules, and Policies applicable to AHCCCS programs
• AHCCCS program design and implementation, prior authorization functions and responsibilities, provider network, and funding source
• Familiarity with American Indian Tribes, programs and policy
Skills:
• Problem solving identification, evaluation, and imitation of appropriate action and case management assessment
• Excellent verbal/written communication skills, with FFS Providers
• Organizational skills to coordinate, monitor and report on multiple cases simultaneously
• Analytical skills to identify and correlate specific patterns, initiate investigations, submit findings and recommendations
• Strong interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds
• Documentation, research, and reporting of data and trends
• Strong computer skills including Microsoft and Google Suite
Abilities:
• Strong ability to collaborate with others for mutually beneficial outcomes
• Interpret clinical information and assess implications for treatment
• Read, interpret, and apply complex rules and regulations
• Independent decision making yet knowing when to elevate the decision
• Drive long distances when required
• Ability to work Telecommute
| Selective Preference(s): |
Arizona Driver's License
Minimum: Three or more years clinical and programmatic experience working with the behavioral health service delivery systems. Behavioral Health Professional (independent/associate license within AZ), Licensed Nurse and/or related licensed professional.
Preferred: Advanced experience in clinical and/or claims supportive documentation review and analysis.
| Pre-Employment Requirements: |
• Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions.
If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements.
All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
| Benefits: |
Among the many benefits of a career with the State of Arizona, there are:
• 10 paid holidays per year
• Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)
• Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child (pilot program).
• Other Leaves - Bereavement, civic duty, and military.
• A top-ranked retirement program with lifetime pension benefits
• A robust and affordable insurance plan, including medical, dental, life, and disability insurance
• Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)
• RideShare and Public Transit Subsidy
• A variety of learning and career development opportunities
By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.
Learn more about the Paid Parental Leave pilot program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page
| Retirement: |
Lifetime Pension Benefit Program
• Administered through the Arizona State Retirement System (ASRS)
• Defined benefit plan that provides for life-long income upon retirement.
• Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.
• Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).
Deferred Retirement Compensation Program
• Voluntary participation.
• Program administered through Nationwide.
• Tax-deferred retirement investments through payroll deductions.
| Contact Us: |
Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.
Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.