Quality Management Nursing Consultant

divh2Quality Management Nursing Consultant/h2pThis position will work independently applying clinical knowledge, judgment, and expertise to assess, coordinate, and monitor service delivery. This position will complete comprehensive assessments of available resources on service providers and individual members; review case material to ensure compliance with State and Federal regulations and policies; and provide timely resolution of multiple cases assigned. This position will also be responsible for identifying systemic issues for AHCCCS to address. This position will be hybrid with some in-office meetings, on-site investigations at least 20% of your time, and reviews as needed. Occasionally, this position may also participate as needed in urgent on-site investigations and reviews outside of normal business hours and weekends./ppThe 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 States 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./ppMajor duties and responsibilities include but are not limited to:/pulliMonitor 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 quality of care and/or health and safety issues utilizing standardized processes. Track, trend, and monitor the status of cases to ensure accurate and timely completion and appropriate referrals using a centralized case management tracking database. Ensure research and resolution of issues or concerns promptly as assigned and identify systemic issues for AHCCCS to address./liliContributes clinical knowledge to assist in the resolution of quality of care concerns, clinical reviews and Operational Reviews. Completes 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./liliConduct 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 of normal business hours and weekends for immediate and urgent situations./liliEnsure 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 level, interventions, and appropriate resolution./liliDevelop improved processes and procedures to improve the efficiency of the unit. Lead special projects and reviews to ensure completion within the designated timelines. Provide ongoing updates to Management./liliDevelop metrics for population-specific outcome objectives. Tracking, evaluation, analysis, and revision of metrics as needed based on the ongoing analysis of member data./liliProvide education and technical assistance to internal and external stakeholders, as appropriate, regarding covered services, and contractual or policy requirements, accurately and consistently to improve compliance with AHCCCS requirements and improve quality of care and service to AHCCCS members./li/ulpKnowledge, Skills Abilities (KSAs):/ppKnowledge of:/pulliState and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, and LTC Supports and Services/liliCurrent standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care/services/liliData management and utilization review regulations, rules and processes/liliAHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules/liliMedical/nursing practice, medical case management protocols, utilization review protocols as related to the acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, and behavioral/mental health/liliCase management development, implementation, and ongoing review/li/ulpSkill in:/pulliAcute nursing and clinical processes including assessment, planning, intervention, and evaluation/liliClinical assessment skill/liliTechniques to select a particular approach to analyze develop or implement a policy, project management methodologies, and Behavioral Health delivery system/liliProblem-solving techniques, evaluation, and initiation of appropriate action/liliExcellent communication, verbal and written/liliOrganizational skills for setting priorities, workload, and record-keeping/liliStrong interpersonal skills in working with agency management, and people of diverse cultures and socioeconomic backgrounds/liliProject management to meet goals and deadlines/liliResearch and analytical skills/liliDocumentation and reporting of data and trends/li/ulpAbility to:/pulliStrong ability to collaborate with others for a mutually beneficial outcome/liliInterpret clinical information and assess implications for treatment/liliRead, interpret and apply complex rules and regulations/liliIndependent decision making, yet knowing when to elevate an issue or concern/liliAssess variables which impact health and functioning/liliMake effective decisions in a high volume, fast paced environment/liliWrite comprehensive reports/li/ulpSelective Preference(s):/ppMinimum: 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./ppPre-Employment Requirements:/ppSuccessfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agencys 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.)/ppAll newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify)./ppBenefits:/ppAmong the many benefits of a career with the State of Arizona, there are:/pulli10 paid holidays per year/liliPaid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)/liliPaid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child./liliOther Leaves - Bereavement, civic duty, and military./liliA top-ranked retirement program with lifetime pension benefits/liliA robust and affordable insurance plan, including medical, dental, life, and disability insurance/liliParticipation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)/liliRideShare and Public Transit Subsidy/liliA variety of learning and career development opportunities/li/ulpBy 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./ppLearn more about the Paid Parental Leave program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page./ppRetirement:/ppLifetime Pension Benefit Program/pulliAdministered through the Arizona State Retirement System (ASRS)/liliDefined benefit plan that provides for life-long income upon retirement./liliRequired participation for Long-Term Disability (LTD) and ASRS Retirement plan./liliPre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period)./liliDeferred Retirement Compensation Program/liliVoluntary participation./liliProgram administered through Nationwide./liliTax-deferred retirement investments through payroll deductions./lipContact Us:/ppPersons 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. 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./p/ul/div