Claims Jobs in Gilbert az

Job Summary :

The Housing Claims & Prior Authorization Manager, who reports to the Claims Operations Administrator, is tasked with ensuring that prior authorizations and claims for Health and Housing Opportunities (H2O) services are reviewed and processed promptly. This role involves verifying that claims documentation from provider organizations adheres to State, Federal, and AHCCCS regulations, policies, and procedures. Additionally, the manager will oversee compliance with contractual, regulatory, and statutory requirements for Fee-for-Service (FFS) members, as well as AHCCCS members with complex medical and behavioral health needs. This position will be a subject matter expert in rules and regulations related to the H2O grant. The manager will also monitor the utilization of H2O services and analyze information from various sources, including utilization data and audits.

Depending on the unit's needs and leadership discretion, this position may be performed from a Virtual Office (VO) or through Telecommuting. This position will last for three years and possibly longer depending on the availability of funds for the H2O program.

Job Duties :

Major duties and responsibilities include, but are not limited to :

• Adjudicates claims, processes prior authorizations, and enters data. Reviews prior authorization requests for services. Assesses clinical documentation to monitor, evaluate, and authorize services. This includes ensuring medical documentation is appropriately filed, stored, linked to claims and meets rules established for medical necessity, service appropriateness, quality of care, and ensuring compliance with contractual state and federal obligations that govern the provision of covered services.
• Attends internal meetings and keeps up on changes which may impact the H2O program, DFSM, or other issues.
• Coordinates with internal and external customers as needed, participate in clinical staffing as needed, serve as a FFS health plan subject matter expert on the H2O grant, SMI populations, and housing services. Works with H2O contractors as well as grievance and appeals to resolve claims or prior authorization problems.
• Provides supervision, oversight, and training to other members of the H2O claims and prior authorization team. Ensures all staff know how to report suspect fraud, waste, and abuse to the Office of Inspector General and suspect quality of care issues to the DFSM Quality Management team. Develops desk level protocols and procedural improvements. Ensures DFSM policies are reflective of state and Federal regulations.
• Monitors, reviews, analyzes, reports on and discusses data related to processing of H2O prior authorizations and claims. Monitors for trends which may be indicative of fraud, waste and abuse and makes referrals to the Office of the Inspector General as needed. Designs, conducts and oversees program audits.
• Manage and direct subordinate staff (work assignments, setting priorities, hiring, discipline, provide training, approving leave requests, and preparing evaluations).

Knowledge, Skills & Abilities (KSAs) :

Knowledge :

Skills :

Abilities :

Qualifications :

Minimum Qualification : Four years professional experience related to health program appropriate to the assignment, which includes

experience in Healthcare Administration AND Two plus years of managerial experience. Experience with medical claims and coding,

Arizona Medicaid, and medical records.

Preferred Qualification : Bachelors or Masters Degree in Healthcare Administration or in related field. Experience in both behavioral

health administration and medical services administration. Certified coder. Familiarity with PMMIS, Cognos, and / or AHCCCS policies.

Pre-Employment Requirements :

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 :

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 :

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 . For a complete list of benefits provided by The State of Arizona, please visit our

Retirement :

Lifetime Pension Benefit Program

Deferred Retirement Compensation Program