Title : Clinical Review Unit Manager

Job Summary :

Under the direction of the Utilization Review (UR) Administrator, this position is responsible for the management and oversight of Division of Fee for Service Management (DFSM) Clinical Review Unit (CRU) staff, ensuring the timely and accurate completion of clinical reviews in various clinical units within the DFSM. Oversight includes technological aspects, interaction with providers, resolution of provider issues and unit reporting.

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.

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.

Job Duties :

Major duties and responsibilities include but are not limited to :

• Provides direct management of the Clinical Review Unit and manages the nursing staff and non-nursing staff. Participates in Division and Agency Policy Committees. Oversees and directs the technological aspects of the CRU processes and maintains reporting structures and processes.
• Provides oversight and directs team interaction with Fee-for-Service (FFS) Providers and stakeholders, ensures provider issue resolution including grievance and appeals, and provides technical assistance. Works in conjunction with other clinical teams in the DFSM, staff and teams in other AHCCCS divisions, and external partners as required on quality related matters, care coordination needs, policies, procedures, and processes related to health care services.
• Oversight of the team’s participation in special processes (i.e. SMI or SED determination, OHR assistance, seclusion and restraint, out of state placements, etc.) Provides oversight and directs team interactions with FFS Providers, including provider issue resolution and technical assistance.
• Provides backup for the responsibilities held by the CRU nurses as needed.
• Acts as a FFS subject matter expert while assisting in the development of policies and procedures, as required for delivery of covered health care services.

Knowledge, Skills & Abilities (KSAs) :

Knowledge of :

Skilled in :

Ability to :

Selective Preference(s) :

Minimum : Possession of a current license to practice as a registered nurse in the State of Arizona and four (4) years professional experience related to health programs appropriate to the assignment, which includes program planning or administration; AND Two (2) plus years of managerial experience or (2) plus years as an AHCCCS Health Care Nursing Consultant. A Master's degree in a field appropriate to the assignment may substitute for one year of the required experience.

Preferred Qualifications : Professional experience in the health care industry in review and management of utilization, prior authorization, medical claims. With a certification as a professional CPT coder and / or experience in medical coding / billing. Experience working in the tribal healthcare delivery system.

Pre-Employment Requirements :

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 :

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.