Housing Claims & Prior Authorization Manager

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 :

• Medical technology, computer data retrieval and input, including EHR, HIE, etc.
• Medicaid and Medicare Federal Regulations, State Statute, Rules, and Policies applicable to AHCCCS programs
• AHCCCS program design and implementation, prior authorization functions and responsibilities, provider network, and funding source
• Familiarity with American Indian Tribes, programs and policy

Skills :

• Problem solving and evaluation
• Excellent verbal / written communication skills
• Organizational skills
• Data entry skills
• Strong interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds
• Reporting of data and trends
• Strong computer skills including Microsoft and Google Suite

Abilities :

• Strong ability to collaborate with others for mutually beneficial outcomes
• Read, interpret, and apply complex rules and regulations
• Independent decision making yet knowing when to elevate the decision
• Ability to drive long distances when required
• Ability to telecommute

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 :

• Successfully complete the Electronic Employment Eligibility Verification Program (E-Verify), applicable to all newly hired State employees.
• 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 .

AND have an acceptable driving record for the last 39 months including no DUI, suspension or revocations and less than 8 points on your license.

If an Out of State Driver License was held within the last 39 months, a copy of your MVR (Motor Vehicle Record) is required prior to driving for State Business.

Employees may be required to use their own transportation as well as maintaining valid motor vehicle insurance and current Arizona vehicle registration;

however, mileage will be reimbursed.

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 (pilot program).
• 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.
30+ days ago