Title: Informatics Nurse - Pre-Payment Reviewer
Informatics Nurse - Pre-Payment Reviewer - 532583
- PHOENIX
- REMOTE OPTIONS
- AHCCCS
- Full-time
AHCCCSArizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork
The Arizona Health Care Cost Containment System (AHCCCS), Arizonas 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.Informatics Nurse - Pre-Payment ReviewerDivision of Fee for Service Management (DFSM)Job Location:Address: 801 E. Jefferson Street, Phoenix, AZ 85034This position has the potential to work from a Virtual Office (VO) setting or may Telecommute based on the needs of the unit and at the discretion of leadership.Posting Details:Salary: $71,000 - $72,132
Grade: 22
Closing Date: Open until filledJob Summary:The Informatics Nurse position reports directly to Claims Operations Administrator. This position will work independently applying clinical knowledge, judgment, and expertise to assess, coordinate, and monitor service delivery with project components. The position will complete comprehensive data analytics and is responsible for interdisciplinary collaboration representing the division (DFSM) as the data subject matter expert (SME) as it relates to quality and program integrity. This position assists with compliance and monitoring functions, running data reports including analyzing the data, clinical significance and recommendations on next steps. This position will also be responsible for identifying systemic issues for AHCCCS to address. This position works collaboratively with the pre-payment review team to help ensure pre-payment reviews of clinical documents are completed in a timely manner.
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 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.
Job Duties:Major duties and responsibilities include but are not limited to:
* Perform pre-payment review of behavioral health documents submitted in support of behavioral health claims. Including responses to disputes of behavioral health claims.
* Identify trends, issues, outliers which may need to be addressed by DFSM and/or other leaders. Succinctly and clearly summarizes data issues and trends in writing and verbally. Makes direct referrals to OIG, QM and PPR teams as appropriate based on findings.
* Responsible for creating reports and presentations which synthesize information and explain the clinical significance as well as the rationale of findings and recommendations.
* Serve as a DFSM Informatics SME, overseeing all the data for the division, including ODA analytics reports submitted for review to the division. Develop reports in Cognos which can be easily run ad hoc by staff. Including providing technical assistance and training to staff in use of Cognos. Set up special handling's in PMMIS and Alivia.
* Responsible for data analysis project management; creating and maintaining reports & meetings as necessary. Follow-up on written reports, action plans, escalations, education, and other actions as appropriate. Focus on continuous process improvement related to Data and Reporting processes leading projects as needed.
* Provides education, technical assistance to internal and external stakeholders, and participates in various cross agency meetings serving as subject matter expert of the data for the division. Share reports and updates regularly with leadership based on data analysis.
Knowledge, Skills & Abilities (KSAs):Knowledge:
* State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, Behavioral Health, LTC and Tribal and Childrens Rehabilitative Services
* Clinical experience in various medical/behavioral health settings including understanding of the technology and information
* Current standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care services
* Data analysis, data management and utilization review regulations, rules and processes and interpretation
* AHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules
* Structure and operation of the Arizona behavioral health system
Skills:
* Advanced skills in Microsoft Office (SharePoint, Excel, Access) and Google suite
* Problem-solving techniques, evaluation, and initiation of appropriate action
* Excellent communication, verbal and written skills
* Organizational skills for setting priorities, workload, and record-keeping
* Strong interpersonal skills in working with agency management, cross divisional, and interdisciplinary groups including people of diverse cultures and socioeconomic backgrounds
* Project management skills including system implementation, process improvement and ability to meet goals and deadlines
* Research and analytical skills
* Documentation and reporting of data and trends with clinical significance
* Behavioral Health processes including assessment, treatment planning, intervention, and evaluation
* Acute nursing and clinical processes including assessment, planning, intervention, and evaluation
Abilities:
* Explain complex data in a succinct and clear manner that people can understand
* Understand complex data reports
* Read and interpret a spreadsheet
* Write comprehensive reports such as data-driven decision making and quality improvement to enhance outcomes
* Read, interpret and apply complex rules and regulations
* Adapt to new technology and programs assisting with data analysis and inference/applicability to other areas
Selective Preference(s):Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and three (3) years of relevant healthcare experience. Experience with data analytics or epidemiology.
Preferred: Experience with tribal communities or organizations serving American Indians. Experience in outpatient behavioral health services. Preferred skills in power BI.
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 agencys ability to reasonably accommodate any restrictions.
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 here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page
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.
Contact Us:Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing [email protected].
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.
Remote
- 532583
- PHOENIX
- REMOTE OPTIONS
- AHCCCS
- Full-time
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork
The Arizona Health Care Cost Containment System (AHCCCS), Arizonas 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.
Grade: 22
Closing Date: Open until filled
The Informatics Nurse position reports directly to Claims Operations Administrator. This position will work independently applying clinical knowledge, judgment, and expertise to assess, coordinate, and monitor service delivery with project components. The position will complete comprehensive data analytics and is responsible for interdisciplinary collaboration representing the division (DFSM) as the data subject matter expert (SME) as it relates to quality and program integrity. This position assists with compliance and monitoring functions, running data reports including analyzing the data, clinical significance and recommendations on next steps. This position will also be responsible for identifying systemic issues for AHCCCS to address. This position works collaboratively with the pre-payment review team to help ensure pre-payment reviews of clinical documents are completed in a timely manner.
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 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.
Major duties and responsibilities include but are not limited to:
* Perform pre-payment review of behavioral health documents submitted in support of behavioral health claims. Including responses to disputes of behavioral health claims.
* Identify trends, issues, outliers which may need to be addressed by DFSM and/or other leaders. Succinctly and clearly summarizes data issues and trends in writing and verbally. Makes direct referrals to OIG, QM and PPR teams as appropriate based on findings.
* Responsible for creating reports and presentations which synthesize information and explain the clinical significance as well as the rationale of findings and recommendations.
* Serve as a DFSM Informatics SME, overseeing all the data for the division, including ODA analytics reports submitted for review to the division. Develop reports in Cognos which can be easily run ad hoc by staff. Including providing technical assistance and training to staff in use of Cognos. Set up special handling's in PMMIS and Alivia.
* Responsible for data analysis project management; creating and maintaining reports & meetings as necessary. Follow-up on written reports, action plans, escalations, education, and other actions as appropriate. Focus on continuous process improvement related to Data and Reporting processes leading projects as needed.
* Provides education, technical assistance to internal and external stakeholders, and participates in various cross agency meetings serving as subject matter expert of the data for the division. Share reports and updates regularly with leadership based on data analysis.
Knowledge:
* State and Federal Policies and Procedures governing Title XIX, Title XXI, Managed Care, Behavioral Health, LTC and Tribal and Childrens Rehabilitative Services
* Clinical experience in various medical/behavioral health settings including understanding of the technology and information
* Current standards of medical/ behavioral practice and modes of delivery for acute and non-acute medical/behavioral care services
* Data analysis, data management and utilization review regulations, rules and processes and interpretation
* AHCCCS and Medicaid regulations, policies, and procedures and applicable federal and state statutes, regulations and rules
* Structure and operation of the Arizona behavioral health system
Skills:
* Advanced skills in Microsoft Office (SharePoint, Excel, Access) and Google suite
* Problem-solving techniques, evaluation, and initiation of appropriate action
* Excellent communication, verbal and written skills
* Organizational skills for setting priorities, workload, and record-keeping
* Strong interpersonal skills in working with agency management, cross divisional, and interdisciplinary groups including people of diverse cultures and socioeconomic backgrounds
* Project management skills including system implementation, process improvement and ability to meet goals and deadlines
* Research and analytical skills
* Documentation and reporting of data and trends with clinical significance
* Behavioral Health processes including assessment, treatment planning, intervention, and evaluation
* Acute nursing and clinical processes including assessment, planning, intervention, and evaluation
Abilities:
* Explain complex data in a succinct and clear manner that people can understand
* Understand complex data reports
* Read and interpret a spreadsheet
* Write comprehensive reports such as data-driven decision making and quality improvement to enhance outcomes
* Read, interpret and apply complex rules and regulations
* Adapt to new technology and programs assisting with data analysis and inference/applicability to other areas
Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and three (3) years of relevant healthcare experience. Experience with data analytics or epidemiology.
Preferred: Experience with tribal communities or organizations serving American Indians. Experience in outpatient behavioral health services. Preferred skills in power BI.
* Successfully 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.
All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
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 here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page
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.
Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing [email protected].
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.
About the Company:
Arizona Health Care Cost Containment System (AHCCCS)
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