Public Health Nursing Consultant - Tribal ALTCS

AHCCCS Arizona Health Care Cost Containment System Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s 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. Public Health Nursing Consultant - Tribal ALTCS Division of Fee for Service Management (DFSM) Job Location: Address: 150 North 18th Avenue Phoenix, Arizona 85007 This position may offer the ability to work remotely, within Arizona, based upon the department's business needs and continual meeting of expected performance measures. All AHCCCS Employees must reside within the state of Arizona. Posting Details: Salary: $72,132 FLSA Status: Exempt Grade: 22 Closing Date: February 16, 2026 Job Summary: This position is responsible to monitor, evaluate, and approve/deny the payment of medical and/or behavioral healthcare (BH) services through prospective, concurrent, and retrospective review for the AHCCCS ALTCS Fee for Service populations. It is accountable for the prevention and/or resolution of utilization problems adversely affecting the balance between quality of care, cost effectiveness, and minimization of risk through the use of the utilization management review process. 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: • Review clinical documentation, performs prospective, concurrent and retrospective reviews for medical necessity, appropriateness for admission, length of stay, level of care, quality of care, coordination of care based on State and Federal regulations and policies and procedures governing the provision of covered services. • Work directly and collaborates with providers, Tribal Programs and AHCCCS staff to resolve issues regarding care coordination, utilization review, prior authorization, coverage criteria, policies and procedures, workflow, member needs to support quality outcomes and other issues. Provides education and technical assistance to FFS Providers and Tribal Staff as needed, including identification, research and resolution of member specific and provider issues, to improve compliance with AHCCCS requirements, policies, and procedures. • Monitors specialized programs such as Home Modifications and approvals for participation or payment and reporting of member data. Participates in audits, process improvement and other special projects, work groups and committees to improve the efficiency of care coordination, UM and reporting accuracy and other unit functions. • Evaluates rates and compliance for Specialty and high-cost services (e.g., DME, long term care requests), recommends action and provides on-going monitoring or program policy compliance and reporting of data related to specialty services such as Specialty DME, Exception NF Rates, and Over Institutional Cost services. • Maintain records, prepare reports, and ensure compliance with all regulatory and policy requirements. Tracks and/or performs reviews for compliance related to utilization management processes and Federal and State rules and regulations related to the AHCCCS FFS populations. Devises and submits system generated reports, extracts, and analyses to unit and division management. Maintains documentation files. Knowledge, Skills & Abilities (KSAs): Knowledge of: • Understanding of healthcare delivery systems, mechanisms necessary for coordination and delivery of services • Principles of medical and/or behavioral management and assessment • Current standards of medical and/or behavioral practice, delivery of medical/behavioral care • Current costs, appropriateness & utilization of medical supplies & equipment • Principles of utilization review • Alternate levels of care • ICD-9/10 diagnosis coding; DFM-IVN Diagnosis Coding; CPT procedure coding • Medic

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