Quality Assurance Nursing Consultant

Quality Assurance Nursing Consultant

The Arizona Health Care Cost Containment System (AHCCCS), Arizona's Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility.

AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry.

Come join our dynamic and dedicated team.

Job Summary: This 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.

Major duties and responsibilities include but are not limited to:

• 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 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.
• Contributes 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.
• 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 of normal business hours and weekends for immediate and 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 level, 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 the designated timelines. Provide ongoing updates to Management.
• Develop metrics for population-specific outcome objectives. Tracking, evaluation, analysis, and revision of metrics as needed based on the ongoing analysis of member data.
• Provide 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.

Knowledge, Skills & Abilities (KSAs): Knowledge of:

• State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, and LTC Supports and Services
• Current standards of medical/behavioral practice and modes of delivery for acute and non-acute medical/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 long-term elderly and physically disabled, developmentally disabled, and behavioral/mental health
• 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: