Behavioral Health Prior Authorization Manager

Job Summary:

Under the direction of the Utilization Review (UR) Administrator, this position is responsible for management and oversight of the DFSM Behavioral Health Prior Authorization/Utilization Review (BH PA/UR) of staff and unit processes. Including interaction with Providers, resolution of Provider issues and BH PA/UR reporting. Provide monitoring and technical assistance to ensure compliance with contractual, regulatory, and statutory obligations for the members’ physical/acute care services and behavioral health needs.

Monitor over and under utilization, conduct prior authorization reviews, provide oversight and technical assistance, gather, plan, organize and evaluate information from multiple sources, including utilization data, case file reviews and audits. Participate in complex care management clinical staffing as needed, serve as a subject matter expert for Behavioral Health covered services.

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:

• Provides direct management of the DFSM Behavioral Health Prior Authorization/Utilization Review (BH PA/UR) unit, including supervision of the BH PA/UR nurses and other staff. Oversees and directs the technological aspects of the BH PA/UR process and maintains reporting structure and processes.
• Works in conjunction with the CMSU Team, nurse managers, and other AHCCCS divisions and units, groups and external partners as required on policies and procedures related to behavioral health care services such as SMI determinations, special assistance, seclusion and restraint, access to care and out of state placement requests.
• Oversees and directs interaction with Fee-for- Service Providers, Including Provider issue resolution and technical assistance.
• As needed, provides backup for the responsibilities held by the BH Prior Authorization/Utilization Review unit and other CMSU functions as needed.
• As subject matter expert, assist in the development of policies and procedures as required for delivery of covered behavioral health services.

Knowledge, Skills & Abilities (KSAs):

Knowledge:
• Principles and practice of management and supervision, of data research and report development
• Information technology processes and potential prior authorization processes, heath care delivery systems and mechanisms for coordination and delivery of services
• Principles of behavioral and/or medical nursing management and assessment, current standards of medical/behavioral practice and modes of delivery for acute and non-acute medical/behavioral health care and services.
• Current costs, appropriateness and utilization of behavioral health services
• Principles of utilization review, alternative levels of care, ICD, CPT and DSM coding, and medical billing guidelines
• Interrelations of government entities, Federal and state rules, regulations, statutes, programs, policies, procedures, and codes applicable to AHCCCS programs and populations
• Familiarity with American Indian tribes, and programs and policies relative to Intergovernmental Agreements (IGA)
• Service Authorization concepts, principles, and strategies
• General knowledge of behavioral health service delivery system and the needs of individuals designated as SED or SMI
• Individual service planning process and substance abuse treatment
• Medical technology, computer data retrieval and input, including EHR, HIE, etc

Skills:
• Problem solving identification, evaluation, and imitation of appropriate action, nursing, and case management assessment
• Excellent verbal/written communication skills
• 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 socio-economic backgrounds
• Documentation and reporting of data and trends

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.

Selective Preference(s):

Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona OR Licensed Behavioral Health Professional AND four (4) years professional experience related to health programs appropriate to the assignment, which includes program planning or administration; AND Two (2) plus years of managerial experience or (2) plus years as an AHCCCS Health Care Nursing Consultant. A Master's degree in a field appropriate to the assignment and minimum six (6) years of experience may substitute for the license requirement.

Preferred: Bachelor or Master of Science in Nursing and/or Independent Behavioral Health License, and/or five (5) years of supervisory experience leading a health care team or organization, and national certification relevant to the area of practice.

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 .)

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:
• 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. Learn more about the Paid Parental Leave pilot program here.
• 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 . For a complete list of benefits provided by The State of Arizona, please visit our

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.