Job Description

Position Purpose: The Medical Management Specialist is responsible for completing prior authorization and concurrent reviews for behavioral health services by utilizing pre-approved criteria and guidelines to validate medical necessity. Medical Management Specialist also reviews appropriateness of discharge planning; coordinates discharge planning with outpatient providers; issues Notices of Actions and participates in clinical rounds.

Responsibilities:

  • Conducts prior authorization and concurrent reviews.
  • Assessment of post discharge needs and coordinates of services.
  • Refers members to care management and disease management programs.
  • Completes Notices of Action or Notices of Decision and maintains accurate clinical documentation of authorizations, case management, concurrent review and discharge.
  • Serves as subject matter expert for behavioral health services, and as a resource for program specialties, including cultural appropriateness.
  • Provides support and technical assistance to SHCA and SHCA network of care providers based on the needs of members or of a specific provider.
  • Consults with Medical Director as need to review complex cases.
  • Performs other similar duties as assigned.
  • Ability to work remotely.

Education / Experience / Other Requirements

Education:

  • This position requires a Master’s degree in a behavioral health field, Registered Nurse or an equivalent combination of education and experience sufficient to successfully perform the essential duties of this position.
  • This position also requires an independent behavioral health license for the state of Arizona.

Years of Experience:

  • Minimum 2 Years of experience in behavioral health field.
  • Demonstrated experience working with children and adults with BH needs.
  • Preferred experience with prior authorization and concurrent review process.

Specialized Knowledge:

  • Knowledge of Arizona Medicaid system and behavioral and AHCCCS health systems; psychiatric diagnoses, psychiatric medications and standards of care
  • Knowledge of medical necessity criteria; managed care principles
  • Ability to prioritize and effectively handle multiple projects
  • Communicate effectively both verbally and in writing
  • Use of a variety of computer-based technologies including Microsoft Office applications;
  • Ability to work effectively and efficiently as a team member or independently

Application Instructions

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