GENERAL SUMMARY:

This position is responsible for coordination of all aspects of the patient’s care and services in a facility. Intervention is during hospitalizations and SNF stays. This position will assure that high-quality care is being provided to patients in the most cost-efficient manner though appropriate utilization of health care and community resources. The incumbent is responsible for coordination of discharge planning to insure that case management activities are performed in a timely fashion utilizing approved criteria and protocols. The incumbent communicates with the primary care and specialty physicians, Utilization Management, Discharge Planning, and the Quality Improvements in the hospital, and Care1st staff. This position requires on-going contact with MM Department staff, hospital staff, physicians and Care 1ST Health Plan Arizona Medical Director. The incumbent assures that these functions are performed efficiently and timely.

QUALIFICATIONS:

•	RN or LPN with current License in State of Arizona. Bachelor’s or Associate degree with no less than three (3) years experience in a varied health care.
•	Minimum of one (1) year experience in Managed Care and/or three (3) years experience in UR/UM
•	Case management experience preferred and case management certification preferred
•	Excellent verbal and written communication skills
•	Must be able to work independently and with minimal supervision
•	Arizona State issued driver’s license
•	Must have own reliable transportation with appropriate insurance
•	Strong problem solving skills, organizational skills, and time management skills with the ability to work in a fast paced environment.
•	Must be highly organized with good attitude.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Reviews member in-patient medical records and conducts concurrent review to assess the appropriateness of the hospital setting.
•	Evaluates for the appropriate level or location of care and anticipated length of stay.
•	Communicates with the admitting and primary care physicians on an on-going basis.
•	Participates in patient conferences, family conferences and regular staffing for in-patient admissions.
•	Documentation of information from the patient’s hospital record will be done as necessary along with documentation on discharge planning and interactions with hospital staff, physicians, and vendors.
•	Coordinates home health care and durable medical equipment services and notifies the agencies of their needed services.
•	Functions as liaison and problem solver for all concurrent review related issues.
•	Participates in gathering and reporting data to include quality and utilization indicator information and other applicable information.
•	Assists in developing standards and outcomes for all discharge and case management functions.
•	Maintains confidentiality of the member’s medical information.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.
•	MM decision making is based only on appropriateness of care and service and existence of coverage.
•	We do not specifically reward practitioners or other individuals for issuing denials of coverage of service or care.
•	Financial incentives for MM decision makers do not encourage decisions that result in underutilization.

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GENERAL SUMMARY:

This position is responsible for medical review and completion of prior authorization requests. This person will be completing prior authorization requests that require medical review by a nurse and training prior authorization staff identified as requiring additional training.

SKILLS & EXPERIENCE:

•	Registered Nurse with current License in state of Arizona.
•	Minimum of three (3) years of experience with acute inpatient nursing.
•	Minimum of three (3) years experience in Managed Care.
•	Excellent verbal and written communication skills.
•	Excellent organizational skills.
•	Knowledge of AHCCCS, Medicare, regulations preferred.
•	Computer literate (proficient in MS Office, Excel, Word).
•	Must be highly organized with good attitude.
•	Strong service orientation and professionalism.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Perform prior authorization process by performing clinical review of requests requiring medical review and entering authorizations into the system.
•	Handle telephone requests timely and accurately.
•	Develop and update health plan resources and forms to assist staff in their day to day functions. Provide resources and training to staff upon completion.
•	Assist with the design and updating of PA grids and desktop processes.
•	Assist in reviewing and making revisions to department policies to assure compliance with regulatory agencies.
•	Participate in interdepartmental projects as needed.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program..
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.
•	MM decision making is based only on appropriateness of care and service and existence of coverage.
•	We do not specifically reward practitioners or other individuals for issuing denials of coverage of service or care.
•	Financial incentives for MM decision makers do not encourage decisions that result in underutilization.
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GENERAL SUMMARY: Analyzes and adjudicates health benefit claims and performs other related work as required or assigned.. QUALIFICATIONS: • High school diploma or GED. • 3-4 years of claims processing (AHCCCS preferred). • Knowledge in CPT and ICD-9 codes and medical terminology. • Experience in Medicaid and Medicare guidelines. • Process all HCFA and UB claims. • Analytical skills to resolve complex claims. • Multi-tasked and the ability to identify and trend processing/billing issues. • Must be organized with a positive attitude. • Ability to work as a team player in a professional environment. • Communicate effectively and tactfully in both oral and written form. ESSENTIAL DUTIES AND RESPONSIBILITIES: • Accurately adjudicate claims in accordance with health plan guidelines, company standards, and company procedures. • Maintain minimum production standards as set by Care1st policies. • Maintain a 98% or above accuracy rate. • Review claims for appropriate information and accurate reimbursement. • Prioritizes and manages individual workflow as needed. • Maintain completed and updated set of resource materials necessary for processing claims. • Will attend all company-mandated training and remain current with knowledge in the claims field. • Assist with data entry of claims as needed. • Other duties as assigned. CORPORATE INTEGRITY: • Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program. • Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class. • Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position. • Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

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GENERAL SUMMARY: Under the general supervision of the Claims Director, this position will function in the capacity of a Claims Trainer. The Claims Trainer will act as a claims subject matter expert and will be responsible for evaluating and updating the current training materials, creation and ongoing oversight of a formalized training program, creation and implementation of training modules and conduction of individualized processor training as needed to improve the quality of service provided by Care1st. The Claims Trainer partners with areas such as Provider Network Operations, Prior Authorization and with the Claims Educator to assist in proactively identifying and resolving claims issues through communication, enhanced documentation, and training as needed. QUALIFICATIONS: • Bachelor’s degree with major course work in Instructional Design, Adult Learning Theory, Training, Health Administration or equivalent experience. • Minimum of two years related claims training experience through various training methods (facilitated learning and self-directed learning), including development of curriculum. • Coding certification or background in claims processing a plus. • Advanced listening, oral and written communication skills. • Must possess a positive attitude and be skilled in communicating at all levels. • Strong analytical, computer, and organizational skills required. • Aptitude to research, analyze, and successfully resolve and document issues. • Experience in revising and enhancing existing training materials/ training programs to remain compliant with changing business needs. • Ability to gather and document work methods and procedures and conduct the appropriate level of training to ensure a smooth transition and ongoing compliance without interruption to service levels within the department. • Proven ability to design effective training programs and materials using structured instruction. • Considerable knowledge of Medicare/Medicaid rules and regulations. • Ability to take ownership of projects, independently plan and organize ones own activities, and work with little or no supervision. • Must be extremely proficient in Microsoft Word, Excel and PowerPoint. • Knowledge Worker, Integrity, Flexibility, Communication, Critical Thinking, Customer Focus, Decision Making, Planning and Organizing, Building Strategic Working Relationships, Technical and Professional Knowledge. ESSENTIAL DUTIES AND RESPONSIBILITIES: • Analyze existing documentation/ procedures and formulate a plan to revise and maintain an online training manual and update training materials going forward to remain in compliance with Medicaid/ Medicare guidelines. • Develop a formalized training program for new-hires and existing staff for all lines of business and form types. • Provide expertise and research claims questions and issues to identify gaps in documentation and training; proposing solutions on a go forward basis to improve overall service levels. • Participates in meetings for ongoing projects to proactively develop training materials and training modules for procedural changes. • Coordinates, plans and conducts individual and team training as needed with minimal impact on service levels within the team. • Prioritizes assignments with an awareness of the big picture and the impact on service levels, quality results, and conflicting project deadlines. • Actively coordinates resolution of all claims issues or concerns related to claims identified during the course of business. • Participates in organization’s overall continuous quality improvement efforts. • Maintains a daily working relationship with other internal departments regarding all claims matters. • Identifies and assists in conducting additional office-wide training needed for internal staff. • Performs related duties as assigned by the Claims Director. CORPORATE INTEGRITY: • Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program. • Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class. • Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position. • Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

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GENERAL SUMMARY:

Coordinates claims processing and encounter reporting of services rendered to Care 1st members. Ensure claims processing performance standards are met; manages the claims inventory, direct and supervise claims staff.

QUALIFICATIONS:

•	(5) years claims processing experience.
•	(2) years of Supervisory experience.
•	High school diploma or GED.
•	AHCCCS experience.
•	Knowledge of medical terminology, ICD-9, CPT codes, pricing, and provider contracts.
•	Knowledge of all claims processing types (IE, facilities, HCFA, RX, Dental).
•	Skills to communicate effectively and tactfully in both oral and written form.
•	Good communication skills.
•	Must be a team player and work well with other.
•	Must be highly organized with a positive attitude.
•	Work well with external clients.
•	Basic knowledge of Word, Excel and computer skills.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Coordinate and monitor claims processing operation.
•	Coordinate the AHCCCS encounter reporting and pend correction processing.
•	Write policies and procedures for the claims staff.
•	Handles claims related provider questions.
•	Coordinates claims research projects, and work with IT department.
•	Train, supervise, discipline, hire, recruit and evaluate claims staff.
•	Coordinates with the Trainer/Auditor department to identify training needs and develop training programs.
•	Develop and maintain workplans to resolve issues or manage projects as required or assigned.
•	Set individual and team goals for the staff.
•	Ensure individual and team performance standards for timeliness and accuracy are met.
•	Track, analyze and report information pertaining to performance standards/claims inventory management.
•	Adherence to all organizational policies and procedures.
•	Other duties as assigned.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

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GENERAL SUMMARY:

Analyzes and adjudicates health benefit claims and performs other related work as required or assigned.

QUALIFICATIONS:

•	High school diploma or GED.
•	Minimum of 5 years of claims processing (AHCCCS preferred).
•	Knowledge in CPT and ICD-9 codes and medical terminology.
•	Experience in Medicaid and Medicare guidelines.
•	Process all claim types (HCFA, UB, Dental, Pharmacy).
•	Research, analytical and independent decision making skills.
•	Prior analytical and higher level analyst claims experience.
•	Very detailed oriented and the ability to identify departmental processing issues.
•	A strong understanding of Care1st and state policies, procedures and regulations.
•	Must be organized with a positive attitude.
•	Strong ability to work independently.
•	Excellent computer skills (experience in Word, Excel, Access)
•	Ability to work as a team player in a professional environment.
•	Communicate effectively and tactfully in both oral and written form.
•	Knowledge of PMMIS (AHCCCS) system

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Analyze and research the pended encounters received from AHCCCS.
•	Resolve pended encounters on the PMMIS within the specific timeframes.
•	Complete necessary documentation identifying the examiners adjudication errors for resolution of claim.
•	Document all accepted and deleted encounters in a established database.
•	Communicate and document with Business Analyst on any systematic resolutions/issues.
•	Communicate regularly with AHCCCS on any issues that arise.
•	Produce monthly summary reports to Claims Director and Supervisor identifying adjudication errors.
•	Produce a monthly training document for claims examiners to help eliminate any future pended encounters.
•	Produce monthly report on all resolved encounters.
•	Will attend all company-mandated training and remain current with knowledge in the claims field.
•	Other duties as assigned

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

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GENERAL SUMMARY:

Responsible for delivering high quality customer service to Plan members, providers and Plan personnel in an efficient, effective and timely manner. Responsible for dissemination of information regarding the Plan, benefit coverage and other necessary information, in addition to, handling and following up on member complaints or grievances, transportation requests, member or provider requests, eligibility confirmation, and other duties as required.

QUALIFICATIONS:

•	Thorough knowledge of the principals and protocols of quality customer service and relations and/or HMO Health Maintenance Organization, or Medi-Cal business experience of not less than two years.
•	Ability to effectively communicate verbal/written and work as a team member with all associates in a professional and business manner.
•	Must be customer service orientated/philosophy and be able to work in a diverse, demanding, and evolving environment with strong conflict and problem resolution skills, time management, and organizational skills also desired.
•	Prior ACD, Call Center experience strongly desired including personal computer knowledge using MS Word 6.0 and Excel 5.0 or health care data system experience.
•	Spanish bilingual skills are highly recommended.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Receives phone inquiries via an, Automatic Call Distribution & Management Information System (ACD). Utilizing the company’s CSC Healthcare data system provides accurate information as requested, providing “high quality customer service” in a customary business and professional manner at all times.
•	Responsible for implementing and executing all processes, requests or policies as requested by management in a courteous and efficient manner; including offering a proactive approach to suggestions and recommendations and working or cooperating with all office associates or superior’s effectively.
•	May be required to be fully bilingual (Spanish Language) or other languages defined at time of hire. Must be able to effectively translate proficiently all inquiries including technical and medical terminology.
•	Responsible for responding to inquiries regarding Plan benefits and coverage explanations or issues; including requesting that Plan material, correspondence or special items be mailed to members as requested.
•	Responsible for complete and accurate documentation, coding and follow-up, of all member issues, complaints/grievances in a timely and efficient manner within 24 hours of receipt. When possible resolution should be achieved to all issues. Appropriate interdepartmental referrals should be done.
•	Responsible to meet all performance objectives.
•	If designated, responsible for processing all member transportation requests within 24 hours of receipt and coordinating all aspects of the process with clinic, provider and member as appropriate or necessary.
•	Responsible for thorough follow-up and completion of all member, and provider inquiries or requests; not excluding member maintenance, eligibility confirmation, or special assignments or projects as requested.
•	Responsible for accurate, complete and correct documentation into the CSC/CSIM data system regarding all issues and/or inquiries.
•	Responsible for informing the lead supervisor/ manager on all escalated member issues as appropriate.
•	Responsible to interact with other departments and associates to assist with issues as they present.
•	Responsible to assist with the training of new employees and meet changing performance objectives as necessary.
•	Responsible to always show respect for member confidentiality and privacy, such as, not expressing opinions about members that can be overheard by others.
•	Responsible to utilize all phone protocol and etiquette at all times and maintain a professional image as well.
•	Responsible in providing a pleasant and professional customer service experience to all external and internal customers.
•	Responsible to maintain professional and appropriate behavior (actions/verbal) at all times.
•	Responsible for other projects as requested from time to time.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.

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POSITION SUMMARY:

•	Manage all aspects of refund recoveries, including research, approval, and posting.
•	Track and trend recoveries to determine root cause; provide feedback to management for recommendations for system set up and training enhancements.
•	Provide support for all other recovery areas (Reinsurance and TPL).
•	Identify additional opportunities for recovery, including recommendations for implementation.

SKILLS:

•	Extensive claims processing experience in all claims types requires
•	High level understanding of MHC with knowledge of finance components desirable.
•	Previous experience with TPL and/or reinsurance preferred.
•	Ability to work independently critical.
•	Must be able to effectively interact with management and peers to identify root cause of refund recoveries.

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GENERAL SUMMARY:

Analyzes and adjudicates health benefit claims and performs other related work as required or assigned.

QUALIFICATIONS:

•	High school diploma or GED.
•	3-4 years of claims processing (AHCCCS preferred).
•	Knowledge in CPT and ICD-9 codes and medical terminology.
•	Experience in Medicaid and Medicare guidelines.
•	Process all HCFA and UB claims..
•	Analytical skills to resolve complex claims.
•	Multi-tasked and the ability to identify and trend processing/billing issues.
•	Must be organized with a positive attitude.
•	Ability to work as a team player in a professional environment..
•	Communicate effectively and tactfully in both oral and written form.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Accurately adjudicate claims in accordance with health plan guidelines, company standards, and company procedures.
•	Maintain minimum production standards as set by Care1st policies.
•	Maintain a 98% or above accuracy rate.
•	Review claims for appropriate information and accurate reimbursement.
•	Prioritizes and manages individual workflow as needed.
•	Maintain completed and updated set of resource materials necessary for processing claims.
•	Will attend all company-mandated training and remain current with knowledge in the claims field.
•	Assist with data entry of claims as needed.
•	Other duties as assigned.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

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GENERAL SUMMARY:

Analyzes and adjudicates health benefit claims and performs other related work as required or assigned.

QUALIFICATIONS:

•	High school diploma or GED.
•	Minimum of 5 years of claims processing (AHCCCS preferred).
•	Knowledge in CPT and ICD-9 codes and medical terminology.
•	Experience in Medicaid and Medicare guidelines.
•	Process all claim types (HCFA, UB, Dental, Pharmacy).
•	Research, analytical and independent decision making skills.
•	Prior analytical and higher level analyst claims experience.
•	Very detailed oriented and the ability to identify departmental processing issues.
•	A strong understanding of Care1st and state policies, procedures and regulations.
•	Must be organized with a positive attitude.
•	Strong ability to work independently.
•	Excellent computer skills (experience in Word, Excel, Access).
•	Ability to work as a team player in a professional environment.
•	Communicate effectively and tactfully in both oral and written form.
•	Knowledge of PMMIS (AHCCCS) system.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Analyze and research the pended encounters received from AHCCCS.
•	Resolve pended encounters on the PMMIS within the specific timeframes.
•	Complete necessary documentation identifying the examiners adjudication errors for resolution of claim.
•	Document all accepted and deleted encounters in a established database.
•	Communicate and document with Business Analyst on any systematic resolutions/issues.
•	Communicate regularly with AHCCCS on any issues that arise.
•	Produce monthly summary reports to Claims Director and Supervisor identifying adjudication errors.
•	Produce a monthly training document for claims examiners to help eliminate any future pended encounters.
•	Produce monthly report on all resolved encounters.
•	Will attend all company-mandated training and remain current with knowledge in the claims field
•	Other duties as assigned.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

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GENERAL SUMMARY:

Under the general supervision of Appeals Manager, the Appeals Analyst will be responsible for logging, investigating, handling, resolving, tracking and trending member and provider grievances and appeals including reporting and outcome resolution through correspondence and follow-up. Responsible for dissemination of information regarding the Plan, benefit coverage and other necessary information, or other duties as required consistent with the goals of the Department.

QUALIFICATIONS:

•	Thorough knowledge of the principals and protocols of quality customer services and relations specifically member and provider grievance and appeal process and/or HMO AHCCCS experience.
•	Ability to effectively communicate verbal/written and work as a team member with all associates in a professional and business manner.
•	Must be customer service oriented and be able to work in a diversified, demanding and evolving environment with strong conflict and problem resolution skills.
•	MS Word , Access and Excel computer skills.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Responsible for member appeals and provider claim disputes, conducting investigations and completion of response’s within given timeframes. Must comply with AHCCCS guidelines, policy and standards such as, but not limited to grievance resolution and completion within (30) days of receipt.
•	Responsible for addressing and forwarding quality of care complaints to quality management for resolution and/or assisting in investigation in conjunction with quality management medical review.
•	Participate in regular meetings to review case logs and other matters as assigned.
•	Investigate member and when appropriate provider claim or billing discrepancies and coordinate with claims department in order to successfully achieve corrective actions and resolutions.
•	Responsible for coordinating all necessary correspondence to members and providers regarding grievance and appeals/requests for hearing including, grievance forms, grievance acknowledgement and resolution correspondence in the appropriate language.
•	Responsible for maintaining and reporting all compliance, grievance and appeal data including member files, logs, reports, documentation and tracking information in a consistent & approved format. Must comply with AHCCCS reporting timeframe and format.
•	Responsible for compiling, preparing and reporting all compliance and grievance data monthly.
•	Responsible for formulating/implementing and executing all processes, requests, workflow or policies as requested by management in a courteous and efficient manner, including offering a proactive approach to suggestions and recommendations and working or cooperating with all office associates or management effectively.
•	Must be able to accomplish duties and assignments with minimal supervision.
•	Act as a liaison to all company departments as necessary.
•	Responsible for special assignments or projects as requested by management.
•	Position may at times require weekend overtime and or local travel to attend meetings or seminars.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

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GENERAL SUMMARY:

This position is responsible for receiving and filling requests for information from providers and members, processing prior authorization requests, administering notification of medical services, inpatient hospitalization requests, and processing incoming calls.

SKILLS & EXPERIENCE:

•	High School Diploma/GED required.
•	Knowledge in medical terminology, ICD-9/CPT Coding preferred.
•	Demonstrates problem-solving skills.
•	Strong computer/typing skills.
•	Excellent oral and written communication skills.
•	Excellent listening skills.
•	Strong service orientation with professional and courteous performance.
•	Flexible and adaptable to quick changing environment(s).
•	Ability to work as a team player in a professional environment.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Process requests for Prior Authorization
	a. Treatment request
	b. Inpatient hospitalization
•	Verify eligibility within the database system to members and providers.
•	Code each diagnosis of service and procedures according to standards.
•	Update plan resources.
•	Inform Provider Relations of non-contracted providers.
•	Analyze daily faxed requests to determine coverage and approval utilizing criteria. Utilize nurses for medical reviews when necessary.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.
•	MM decision making is based only on appropriateness of care and service and existence of coverage.
•	We do not specifically reward practitioners or other individuals for issuing denials of coverage of service or care.
•	Financial incentives for MM decision makers do not encourage decisions that result in underutilization.

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GENERAL SUMMARY:

Responsible for review of claims requiring medical/surgical &/or behavioral health review as well as questionable, unusual, or special claims for contract benefits, limitations and exclusions. Requires ability to research all available resources regarding claim status, medical necessity, and grievance.

QUALIFICATIONS:

•	Active, unrestricted Arizona nursing license (RN/LPN).
•	Certified Coder Preferred.
•	Good communication skills.
•	Must be highly organized with good attitude.
•	Minimum of 3 years medical/surgical &/or behavioral health reviews work experience in a defined specialty and/or utilization review experience.
•	Minimum of 3 years coding experience.
•	Good computer skills.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Knowledge of claims processing and coding.
•	Current medical knowledge.
•	Ability to perform critical in-depth analysis of medical records for appropriateness and level of care.
•	Utilization of good judgment and tact in all aspects of work performance.
•	Ability to apply policies and procedures effectively.
•	Completes claims per timelines required by contract.
•	Reviews medical/clincial available information against established criteria (Milliman Care Guidelines, CDST, and claims info to evaluate medical necessity and appropriateness of care.
•	Communicates effectively with management and peers.
•	Identifies and reports any potential quality issues to management, Quality Management as needed.
•	Interface with all Care1st Departments.
•	Excellent verbal and written communication skills.
•	Ability to work as a team player.
•	Ability to travel within Maricopa County.
•	Perform other duties as assigned to fulfill responsibilities of position.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.
•	MM decision making is based only on appropriateness of care and service and existence of coverage.
•	We do not specifically reward practitioners or other individuals for issuing denials of coverage of service or care.
•	Financial incentives for MM decision makers do not encourage decisions that result in underutilization.

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GENERAL SUMMARY:

Performs job responsibilities within the framework of established Company’s procedures, policies, and standards under the direct supervision of the Department Director or Manager.

QUALIFICATIONS:

•	High School Diploma.
•	Proficient in MS Office 97 (Word, Excel, Access, etc.).
•	At least two (2) years of college.
•	Excellent communication skills, both verbal and written.
•	Good organizational skills.
•	Ability to prioritize.
•	Able to multi-task.
•	Ability to work unsupervised.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	Responsible for logging/mailing correspondence to the providers for the Department.
•	Serve as back-up telephone relief for Receptionist/Administrative Assistant.
•	Responsible for the storage and retrieval of all pertinent documents with the on/off site storage facility.
•	Assist in general clerical duties required by Department.
•	Adherence to all organizational policies and procedures.
•	Acts as receptionist for department-greeting visitors in a cordial and business like manner.
•	Handles incoming and outgoing fax transmissions appropriately and timely.
•	Duplicates reports, correspondence etc. accurately and timely.
•	Maintains purchase order files in an orderly manner.
•	Updates manuals accurately and in an orderly manner.
•	Prepares purchase orders for processing in a timely and accurate manner.
•	Types reports for the Director Accurately.
•	Answer incoming calls in a professional manner.
•	Adhere to Personnel Policies and Procedures.
•	Other duties as assigned.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•	Abides by all applicable laws and regulations as mandated by state and federal laws and prevents being excluded or sanctioned from any state and/or federal programs as they pertain to healthcare.

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GENERAL SUMMARY:

The position is responsible for the facilitation, implementation and coordination of the EPSDT Member Outreach Program and the overall compliance with immunization and EPSDT examinations. The position serves as the health plan resource for EPSDT/Well Child Program components including the monitoring of lead levels, and is the liaison between AzEIP, WIC, Head Start, Care1st Health Plan Arizona providers and Members. The position makes recommendations for a selection of alternative methods and procedures, however the employee may be required to utilize independent judgment based on precedents set by similar situations and by referring issues requiring administrative review to the Director of Quality Management and the CMO.

QUALIFICATIONS:

•	Minimum of two (2) years in Pediatrics background preferred.
•	Extended education/experience in a healthcare setting preferred.
•	HMO/Managed care experience preferred.
•	AHCCCS experience helpful.
•	Chart review/audit experience preferred.
•	Must demonstrate excellent written and verbal communication skills.
•	Good communication skills in both Spanish and English required.
•	Must be highly organized with good attitude.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

•	1. The primary responsibility for this position is to ensure access to periodic preventive health care for members 0-21 years by:
	a) Promoting and coordinating child wellness initiatives
	b) Conducting ongoing notifications of periodic screening requirements to providers and members either via monthly mailings and/or telephone calls
	c) Developing and implementing an ongoing outreach program strategy to promote EPSDT visits
	d) Tracking immunizations for the 12-24 month old members
	e) Tracking specialty service referrals and correlating with service dates
	f) Conducting EPSDT audits on a rotating schedule, as per the EPSDT guidelines
	g) Developing educational materials and/or providing training to providers and/or Members
	h) Recommends and evaluates potential incentive programs for components of EPSDT/Well Child program
	i) Developing quarterly EPSDT participation reports
	j) Represents Care1stHealth Plan of Arizona at community coalitions and at AHCCCS meetings
	k) Collaborates with the MCH/EPSDT Supervisor/Coordinator and the EPSDT Outreach Coordinator to effectively manage the EPSDT membership
	l) Participate in the implementation of any required newly developed health initiatives
•	2. Adheres to institutional polices to assure consistency and quality health care delivery.
	a) Adheres to Care1st policies and procedures.
	b) Assist in development and necessary revisions of EPSDT/Wellness and Dental policies and procedures.
	c) Assumes responsibility for attendance at meetings.
	d) Assumes responsibility for a professional appearance.
	e) Adheres to an ethical code of confidentiality.
•	3. Ensures professional self development.
	a) Participates in a formal self evaluation process.
	b) Demonstrates currency of practice.
•	4. Supports and adheres to Care1st philosophy that provision of quality service to members and provides is the highest priority.
	a) Maintains a professional demeanor in all dealings with providers and co-workers.
	b) Treats patient information in a confidential manner.
	c) Communicates with other personnel/departments in a professional, caring and effective manner.
•	5. Contributes to continuous quality improvement activities.
	a) Participates, as appropriate, in department’s continuous quality improvement plan by measuring assessing and improving performance in order to impact the overall quality of clinical and support activities/processes.
•	6. Performs other related job duties as assigned.

CORPORATE INTEGRITY:

•	Understands and abides by all departmental policies and procedures as well as the organization’s Corporate Integrity Program.
•	Attends mandatory Corporate Integrity Program education sessions, as required for this position, including the annual mandatory Standards of Conduct class.
•	Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position.
•