This position reports within the client Quality Management Unit and conducts quality of care investigations pursuant to the contract between the client and the Health Care Cost Containment System. This position participates in the investigations of member-centric and systemic quality of Care Concerns to ensure member health and well-being. Conducts timely, thorough, member centric and systemic investigations for all division member quality of care issues and places vendor-specific corrective action plans in place utilizing a standardized process.

Make appropriate referrals to oversight and regulatory agencies.

Participates in Care Concerns, Care Needed Today, and member issues as assigned.

Maintains all necessary documentation to support case work.

Request appropriate documentation for quality-of-care investigations and ensure maintenance of comprehensive case records to support allegation review and substantiation levels.

Appropriately elevates cases and/or trend concerns to QOC supervisor.

Skills:

Critical thinking Technological skills including use of databases

Microsoft Office products, email and electronic referral and verification sources.

Producing professional technical reports and letters.

Research and analysis.

Oral and written communication skills.

Personal planning, organization and time management.

Medical chart review.

Nursing Process, including assessment, monitoring, and evaluation.

Decision making skills.

Critically analyze problems and develop effective plans for corrective action.

Physician Responsibilities:

The physician positions are essential to the ECR process.

Physicians will serve as the primary clinical reviewers and certify their cases.

They will review the assessment and available supporting records, consider information submitted by the member or health care decision-maker, seek discipline-specific consultation when needed, and document a clear clinical recommendation and rationale using the client’s ECR process and templates.

We are recruiting for physicians who can evaluate complex needs, synthesize information from multiple sources, document their reasoning clearly, and complete assignments within required timelines (48 hours from case assignment).

Members will be ages 0-18, so knowledge of pediatrics and adolescent and teenage development is essential.

Experience with people with developmental disabilities, complex medical or behavioral needs, and interdisciplinary review would be especially valuable.

Consultative Clinical Responsibilities:

Social workers, BCBAs, and occupational therapists will be available to provide expertise within their respective disciplines only when reviewing physician requests consultation.

They will not serve as the primary reviewers or certify cases.

We cannot guarantee a set number of consultations, assignments, or hours for these roles.

Anticipated Volume:

Approximately up to 20,000 cases will need to move through the process during the first three months. (This is a planning estimate, not a guaranteed case count, completion date, or individual workload).

Anticipate substantial demand for physician reviewers during implementation, potentially approaching full-time availability for an extended period.

Anticipate Availability:

Actual hours will depend on case volume, staffing, and the pace at which cases become ready for review.

We anticipate that each case may take 1-3 hours for review and documentation.

Turnaround time from receipt is 48 hrs.

We can grant additional time only in extenuating circumstances.

Additional time may be granted if records are needed or if communication with the health care decision maker is needed.

Required Education for All Roles:

This position requires that the successful candidate possess and maintain an active license and schooling to practice in AZ

Behavioral Analyst- Requirements:

Board Certified – completed additional requirements and passes an examination demonstrating expertise in a particular medical specialty.

Qualifying graduate degree: masters or higher

Passed the BCBA certification examination

Meet AZ licensure requirements for the role

Training and Requirements:

All candidates should be comfortable completing ECR-specific training, following standardized review and documentation procedures, identifying potential conflicts of interest, and responding promptly to assignments and requests for clarification.

Familiarity with the PEDI-CAT is required, but we will provide training if needed.

Schedule and Work Requirements:

These positions will primarily work remotely.

Business needs may require clinicians to report to a division office in person

Starting at 40 hours per week

Anticipate cases being assigned between 8 AM and 8 PM.

Cases will be assigned any day of the week, including weekends and holidays.

Starting at 40 hours per week. The work will eventually shift to an as-needed basis

The team will provide more detail about training, assignment timelines, shifts, and remote or hybrid arrangements once those operational expectations are finalized.

Notes:

Hybrid