This position is part of the Division of Developmental Disabilities Quality Management Unit and is responsible for conducting quality of care investigations as per the contract with the Arizona Health Care Cost Containment System (AHCCCS). The role involves investigating member-centric and systemic quality of care concerns to ensure the health and well-being of members. The position requires conducting timely and thorough investigations and implementing vendor-specific corrective action plans using a standardized process.
- Make appropriate referrals to oversight and regulatory agencies.
- Participate in Care Concerns, Care Needed Today, and member issues as assigned.
- Maintain all necessary documentation to support case work.
- Request appropriate documentation for quality-of-care investigations and ensure maintenance of comprehensive case records.
- Elevate cases and/or trend concerns to the supervisor when necessary.
Skills
- Critical thinking and technological skills, including the use of databases.
- Proficiency in Microsoft Office products, email, and electronic referral and verification sources.
- Ability to produce professional technical reports and letters.
- Strong research and analysis skills.
- Excellent oral and written communication skills.
- Effective personal planning, organization, and time management.
- Experience with medical chart review.
- Understanding of the nursing process, including assessment, monitoring, and evaluation.
- Strong decision-making skills and ability to critically analyze problems.
Schedule and Work Requirements
- Primarily remote work, with potential in-person reporting as needed.
- Starting at 40 hours per week, with eventual shift to an as-needed basis.
- Cases assigned between 8 AM and 8 PM, any day of the week, including weekends and holidays.
- Further details on training, assignment timelines, shifts, and remote or hybrid arrangements will be provided by the team once finalized.
Physician Responsibilities
- Serve as primary clinical reviewers and certify cases.
- Review assessments and available supporting records, consider information submitted by members or health care decision-makers, seek discipline-specific consultation when needed, and document clear clinical recommendations and rationale.
- Evaluate complex needs, synthesize information from multiple sources, document reasoning clearly, and complete assignments within required timelines (48 hours from case assignment).
- Knowledge of pediatrics and adolescent development is essential.
- Experience with developmental disabilities, complex medical or behavioral needs, and interdisciplinary review is valuable.
Consultative Clinical Responsibilities
- Social workers, BCBAs, and occupational therapists will provide expertise within their respective disciplines when consultation is requested.
- They will not serve as primary reviewers or certify cases.
- No guarantee of a set number of consultations, assignments, or hours for these roles.
Anticipated Volume
- Approximately up to 20,000 cases will need processing during the first three months.
- Substantial demand for physician reviewers during implementation, potentially requiring full-time availability for an extended period.
Anticipate Availability
- Actual hours will depend on case volume, staffing, and the pace of case readiness for review.
- Each case may take 1-3 hours for review and documentation.
- Turnaround time from receipt is 48 hours, with extensions granted only in extenuating circumstances.
Required Education for All Roles
Successful candidates must possess and maintain an active license and appropriate education to practice in the relevant field.
Physician/Pediatrician/Psychiatrist Requirements
- Board Certified, having completed additional requirements and passed an examination demonstrating expertise in a medical specialty.
- Earned an MD or DO degree from a medical school.
Training and Requirements
- Comfortable completing ECR-specific training and following standardized review and documentation procedures.
- Identify potential conflicts of interest and respond promptly to assignments and requests for clarification.
- Familiarity with the PEDI-CAT is required, with training provided if needed.