Quality Assurance Nursing Consultant

Quality Assurance Nursing Consultant Division of Fee for Service Management (DFSM) Job Location: Phoenix – 150 North 18th Avenue, Phoenix, Arizona 85007; Tucson – 7202 East Rosewood Street, Suite 125, Tucson, Arizona 85710. 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. The role involves completing comprehensive assessments of available resources on service providers and individual members; reviewing case material to ensure compliance with State and Federal regulations and policies; and providing timely resolution of multiple cases assigned. The position also identifies systemic issues for AHCCCS to address. The role is hybrid, requiring some in‑office meetings, on‑site investigations at least 20% of the time, and occasional urgent on‑site investigations and reviews outside normal business hours and weekends. Major duties and responsibilities 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 issues utilizing standardized processes. Track, trend, and monitor case status to ensure accurate and timely completion and appropriate referrals using a centralized case management tracking database. Ensure prompt research and resolution of issues and identify systemic issues for AHCCCS to address. Contribute clinical knowledge to assist in the resolution of quality of care concerns, clinical reviews, and operational reviews. Complete 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 normal business hours and weekends for 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 levels, 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 designated timelines and provide ongoing updates to management. Develop metrics for population-specific outcome objectives. Track, evaluate, analyze, and revise metrics as needed based on ongoing analysis of member data. Provide education and technical assistance to internal and external stakeholders regarding covered services and contractual or policy requirements, accurately and consistently, to improve compliance with AHCCCS requirements and enhance quality of care and service to members. Knowledge of State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, and LTC Supports and Services Current standards of medical and behavioral practice and modes of delivery for acute and non-acute medical and 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, elderly, physically disabled, developmentally disabled, and behavioral/mental health populations 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 initiation of appropriate action Excellent communication, verbal and written Organizational skills for setting priorities, workload, and record‑keeping Strong interpersonal skills in working with agency management and people of diverse cultures and socioeconomic backgrounds Project management to meet goals and deadlines Research and analytical skills Documentation and reporting of data and trends Ability to Strong ability to collaborate with others for a mutually beneficial outcome Interpret clinical information and assess implications for treatment Read, interpret, and apply complex rules and regulations Independent decision making, yet knowing when to elevate an issue or concern Assess variables which impact health and functioning Make effective decisions in a high‑volume, fast‑paced environment Write comprehensive reports Selective Preference(s) Minimum: Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and 3 years of relevant healthcare experience. May require a valid Arizona Driver License for travel‑related duties. Preferred: Experience in prior authorization, utilization management, claims review, auditing, or managed care; knowledge of population served. 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. Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2‑10‑207.12). 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 offered by the State of Arizona are: 10 paid holidays per year Paid vacation and sick time off (13 and 12 days per year respectively) – start earning from day one (prorated for part‑time employees) Paid parental leave – up to 12 weeks per year for newborn or newly‑placed foster/adopted child 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 Remote work is available in full‑time or part‑time schedules to improve work/life balance and job satisfaction. Retirement Lifetime Pension Benefit Program Administered through the Arizona State Retirement System (ASRS) – a defined benefit plan that provides for lifelong income upon retirement. Participation is required for LTD and the 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, administered through Nationwide, with tax‑deferred retirement investments via 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 View email address on click.appcast.io. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer. #J-18808-Ljbffr Arizona State Government