MERCY MARICOPA INTEGRATED CARE Job list* Position Integrated Health Care Development Officer Chief Clinical Officer Arizona-licensed clinical practitioner Children's Medical Arizona-licensed physician, board-certified in child/adolescent psychiatry, or board certified in general psychiatry Children's System Arizona-licensed clinical practitioner Cultural Sensitivity Training and Workforce Development Pharmacy Arizona-licensed pharmacist Is an individual with experience in behavioral and physical health care systems including familiarity with Medicaid and Medicare systems; is responsible for coordinating and overseeing activities of Contractor s Integrated Health Care Office including the Integrated Health Care Plan. Is responsible for clinical program development and oversight of service delivery; acts as the single point of contact for coordination of care with system stakeholders including ADES/DDD, ADES/DCYF, and other state agencies when necessary. Is responsible for clinical-medical programs for children and adolescents and QM and UM/MM programs for children and adolescents. Collaborates with child welfare, juvenile corrections, juvenile detention systems, and other child-serving agencies; is responsible to oversee the children s service delivery system consistent with Exhibit 5, Arizona Vision-Twelve Principles for Children Service Delivery. Is responsible for implementing Contractor s Cultural Competency Program, the Cultural Competency Plan; oversight of all provisions in Section 12, Cultural Competency. Is responsible for developing and implementing training programs; workforce recruitment; oversight of training requirements. Is responsible to manage and oversee programs for prescription drug and pharmacy services; provides education, awareness and management of potential side effects of medications and drug interactions; monitors the effectiveness of medication services.
Quality Management Arizona-licensed registered nurse Performance Quality Improvement Certified Professional in Healthcare Quality (CPHQ) or has comparable education and experience in data and outcomes measurement Medical Management If required to make medical necessity determinations: Arizona-licensed registered nurse, physician or physician s assistant; If not required to make medical necessity determinations: Master s degree in health services, health care administration, or business administration Customer Service Develops, implements, manages and oversees Contractor s QM plan in collaboration with the CMO and the Utilization Review ; is responsible for the following primary functions: Ensures individual and systemic quality of care; Integrates quality throughout the organization; Implements process improvement; Investigates, evaluates resolves, tracks and trends quality of care concerns; Ensures a credentialed provider network. Is responsible for improving clinical quality performance measures; develops and implements performance improvement projects; utilizes data to develop intervention strategies to improve outcomes; and Reports quality improvement/performance outcomes. Is responsible for the following primary functions: Consistently applies appropriate inpatient and outpatient medical necessity criteria; Conducts appropriate concurrent review and discharge planning of inpatient stays; Develops, implements and monitors care coordination and care management functions; Monitors, analyzes and implements appropriate interventions based on utilization data, including identifying and correcting over or under utilization of services; Oversees Arizona licensed nurses, physicians or physician s assistants to coordinate prior authorization, certification and recertification of need functions twenty-four (24) hours per day, seven (7) days per week; Performs and coordinates concurrent review and retrospective review, including PASRR requirements. Manages and oversees systems for entry point access to the health care delivery system; is responsible for the following primary functions: Triage of all inquiries including information inquiries, service requests, crisis phone calls, complaints, grievances, appeals and quality of care issues; and Compliance with standards for resolution, telephone abandonment rates and telephone hold times.
Network Development Housing Employment/Vocational Information Systems Claims/Encounters Grievance System Licensed attorney or has a Juris Doctor degree from an accredited institution Contract Compliance Manages and oversees network development, network sufficiency and network reporting functions; is responsible for network provider adequacy and appointment access; develops network resources in response to unmet needs; assures member choice of providers; oversees timely inter-provider referrals and associated appointment access; resolves provider complaints; resolves disputes between providers; Coordinates provider site visits; reviews provider profiles; implements and monitors corrective action plans as needed; submits provider service delivery reports. Acts as the interagency liaison with ADOH; manages and oversees housing programs, including grants, special housing planning initiatives, and development and expansion of housing availability for members. Acts as the interagency liaison with ADES/RSA; manages and oversees vocational rehabilitation and employment support programs; vocational, employment; and business development services. Manages, oversees and is responsible for developing, maintaining and operating all components of Contractor s Management Information Systems, related systems and data interfaces. Manages, oversees and is responsible for all components and processes related to submitting timely and accurate claims and encounters; assists with the prompt resolution of provider complaints and inquiries; facilitates the exchange of information between grievance, claims processing, and provider relations systems and providers; is responsible for the following primary functions: Educates staff and providers on claims submission requirements, coding updates, electronic claims transactions and electronic fund transfer; Available Contractor resources such as provider manuals, web site and fee schedules; Interfaces with the Contractor s call center to compile, analyze, and disseminate information from provider calls; Identifies trends and guides the development and implementation of strategies to improve provider satisfaction. Manages, oversees, implements and administers all grievance system processes and requirements for members, subcontractors and providers; is prohibited from acting as or under the supervision of Contractor s in-house legal counsel, retained legal counsel, corporate counsel or risk management attorney. Manages and oversees overall compliance with Contract requirements; monitors the submission of Contract deliverables to ADHS/DBHS; coordinates responses to ADHS/DBHS inquiries; coordinates the execution of Contract requirements and related compliance actions, including ADHS/DBHS Administrative Reviews, audits, corrective actions and ad hoc visits
Individual and Family Affairs Communications/Public Relations Tribal Prevention Maternal Health/EPSDT Arizona-licensed nurse, physician or physician's assistant or has a Master's degree in health services, public health, health care administration or other related field, or a CPHQ or CHCQM Oral Health Liaison Builds partnerships with individuals, families, youth, and key stakeholders to promote recovery, resiliency and wellness; establishes structure and mechanisms to increase the member and family voice in areas of leadership, service delivery and Contractor decision-making committees and boards; advocates for service environments that are supportive, welcoming and recovery oriented by implementing Trauma Informed Care service delivery approaches and other initiatives; communicates and collaborates with members and families to identify concerns and remove barriers that affect service delivery or member satisfaction; 18.6.19.5 promotes the development and use of member and family support programs; 18.6.19.6 Collaborates with ADHS/DBHS Office of Individual and Family Affairs. Responds to media inquiries and is responsible for public relations, social marketing and outreach activities; obtains approvals for communications materials; coordinates and oversees the distribution of information including the member handbook, provider handbook, brochures, newsletters and information on Contractor s web site; collaborates with ADHS/DBHS Communications Director and attends regular status updates and planning meetings as directed by ADHS/DBHS. Acts as the liaison with tribal nations; is responsible to address issues related to tribal structure and organization; promotes services and programs to improve the health of American Indian members including coordination of care; acts as the single point of contact regarding delivery of health services or any other issues concerning American Indians. Acts as the primary liaison to ADHS/DBHS Prevention Services; manages, oversees, implements and administrates Contractor s prevention services programs. Is responsible for the following primary functions: Assures receipt of EPSDT services for SMI members age eighteen (18) through twenty (20); Assures receipt of maternal and postpartum care; Promotes family planning services; Promotes individual preventive health strategies; Identifies and coordinates assistance for identified member needs; Collaborates with community and system stakeholders. Is responsible for the oversight of dental service delivery for SMI members age eighteen (18) through twenty (20); is responsible for identification of available oral health community resources to members that do not have dental services coverage; is responsible to collaborate with providers and other community resources to improve access to oral health care services for members that do not have dental services coverage; may be an employee or subcontractor.
AHCCCS Eligibility Liaison Arizona State Hospital Liaison Human Rights Committee Liaison Physical Health Plan and Provider Member Transition Emergency Response/Business Continuity and Recovery Liaison Court Liaison Oversees AHCCCS eligibility screening and referral requirements. Is the single point of contact with the Arizona State Hospital and ADHS/DBHS to coordinate admissions, ongoing care, and discharges for members in the Arizona State Hospital. Is the single point of contact with the regional Human Rights Committee (HRC) and the ADHS/DBHS Human Rights Committee ; is responsible to provide information to the HRC and attend HRC meetings. Is the single point of contact regarding coordination of care with AHCCCS Health Plans and PCPs specifically to facilitate the sharing of clinical information for members not eligible to receive physical health care services. Manages, oversees and coordinates inter-rbha transfers, transfers from health plans, transfers to ALTCS contractors and transfers to other agencies or systems; Locates the member s affiliated clinical provider in the Contractor s system; gathers, reviews and communicates clinical information requested by PCPs, Acute Care Plan Behavioral Health s, other treating professionals, and other involved stakeholders including providers under contract with ADES/CPS and ADES/DDD; responds to and resolves administrative and programmatic issues identified or communicated by PCPs, Acute Care Plan Behavioral Health s, other treating professionals, and other involved stakeholders; problem solves case management and medical management issues; identifies and addresses clinical issues requiring immediate attention; and Collaborates and coordinate with the Acute Care Health Plans regarding member specific issues or needs. Is the single point of contact to coordinate health response needs, recovery, and business functions in the event of a disaster, power outage or other event that causes a significant disruption in service delivery or business operations. Is the single point of contact to communicate with the court and justice systems, including interaction with Mental Health Courts, Drug Courts, and other jail diversion programs; is the interagency liaison with ADJC, ADOC, and AOC. *This list contains titles and partial general descriptions of positions that Mercy Maricopa may seek to fill. Please visit www.aetna.com to view more complete information on positions currently available, as well as important legal notices. If you have a disability and need assistance to apply for a position, please call 1-800-238-6247 and ask to speak with a specialist about an accommodation.