Title: H2O Claims & Prior Authorization Specialist

Job Summary :

Under the direction of the H2O Claims & Prior Authorization manager, this position is responsible for ensuring prior authorization, claims, and audits for the state-wide H2O health program to the AIHP Serious Mental Illness (SMI) population are reviewed and processed promptly.

The claims and prior authorization specialist will verify that prior authorization requests and claims documentation from the H2O program administrator and provider organizations adhere to State, Federal, and AHCCCS regulations, policies, and procedures.

This position will assist the manager with monitoring the utilization of H2O services, collect data, and conduct program audits as directed.

This position is funded by a grant and is contingent upon the availability of funding.

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.

Collects data related to prior authorization and claims processing data.

Responds to inquiries related to prior authorization processes, denials, reconsiderations and other miscellaneous issues.

Works with H2O contractors as well as grievance and appeals to resolve claims or prior authorization problems.

• Conducts and oversees audits of prior authorizations and claims. Reports suspect fraud, waste, and abuse to the Office of Inspector General and suspect quality of care issues to the DFSM Quality Management team.
• Writes, types, or enters information into computer via MS Word, MS Excel or other departmental systems, using keyboard, to prepare documents or reports.

System routing and processing of incoming RightFax documents for Prior Authorization and Claims gatekeeper in accordance with established guidelines to ensure accurate routing.

Reviews and links scanned, faxed and on-line supplemental documents to the appropriate claim using agency systems.

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
• Work Virtual Office or Telecommute or both

Qualifications :

Arizona Drivers License

Minimum Qualifications : 2+ years in a customer service role and 1-2 years' experience with compliance audits, program monitoring, or similar work.

A minimum of one year experience in the healthcare field.

Preferred Qualifications : Bachelor's degree in public administration, pubic health, business administrator, or similar.

Experience working with tribal facilities and the various health care delivery systems in which tribal members may receive services.

Prefer 6 months to 1 year knowledge and experience with PMMIS Eligibility, Claims and / or Prior Authorization.

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 R2-10-207.

12.) 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 : Driver’s License Requirements.

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 here.