This position reports within the client Quality Management Unit and conducts quality of care investigations pursuant to the contract between the client Health Care Cost Containment System (HCCCS). 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).

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.

Required Education for All Roles:
This position requires that the successful candidate possess and maintain an active license and schooling to practice in the State of Arizona

Physician/Pediatrician/Psychiatrist- Requirements:
Physician: Eared an MD or DO degree from medical school

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

Social Worker- Requirements:
Master Social Worker (LMSW): Master’s Degree
Clinical Social Worker (LCSW): Master’s degree

Occupational Therapists - Requirements:
Occupational Therapist License: Master’s Degree or Doctoral

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.

Notes:

Hybrid