Medical Management Manager

Medical Management Manager position with the Arizona Department of Child Safety (DCS), a social and human services agency focused on strengthening families, ensuring safety, and achieving permanency for Arizona’s children through prevention, services, and support.

About the role

The Medical Services Manager oversees daily operations of the health and dental programs within DCS's Comprehensive Health Plan (CHP). This role guides utilization management activities, supports decisions on complex cases, and ensures processes meet State Contract requirements—from medical necessity reviews to care coordination. The manager analyzes medical management data and quality initiatives to identify trends, support evidence-based practices, and implement improvements. The position involves cross-team collaboration to enhance patient outcomes, reduce unnecessary utilization, and improve the overall quality of care for children and youth served by the plan.

Responsibilities

• Manages staff in a select area of the DCS CHP healthcare delivery system (physical and dental health), including Registered Nurses and Clinical Care Coordinators.
• Responsible for daily review and monitoring of team workflows and processes to ensure compliance with plan, policy, and regulatory standards within the medical management area.
• Monitors timeliness of utilization activities.
• Conducts and collaborates on clinical case reviews, medical consultations, Child and Family Team (CFT) meetings, and care conferences.
• Participates in on-call rotation and handles incoming inquiries from members, providers, caregivers, and DCS staff.
• Creates, edits, and revises policies annually, and assists the team with monthly, quarterly, and annual deliverables as determined by AHCCCS.
• Formulates and updates plans and priorities to address departmental or operational challenges.
• Hires, trains, coaches, and audits the Medical Management Team.
• Acts as a clinical reviewer and mentor on complex cases, including pharmacy or service prior authorizations, as well as case reviews for high-utilization members or risk management cases.
• Implements and evaluates the Medical Management program and work plan in accordance with DCS mission, strategic goals, and federal and state laws and regulations.
• Resolves and communicates utilization management issues, corrective action plan activities, and reporting.
• Participates in joint operating meetings with DCS CHP's contracted health plan and assists with clinical projects and plans.
• Collaborates to ensure integration, quality, and efficiency of utilization management.
• Reviews and analyzes health data, including inpatient, outpatient, and pharmacy data, to identify trends, potential areas for system updates/changes, and training opportunities (internal and external).
• Reviews, analyzes, and reports utilization metrics.
• Facilitates or leads various committee structures and presents at the Quality Management and Medical Management Committees.
• Leads review of regulatory standards impacting Utilization Management/Prior Authorization.
• Represents Medical Management in external meetings and activities.
• Performs other duties as assigned related to the position.

Requirements

• Independently licensed physical and/or behavioral health clinician with an unrestricted Arizona license: Registered Nurse (RN), Nurse Practitioner (NP), or Physician (MD/DO).
• Minimum of five (5) years' nursing experience or equivalent.
• Ability to secure and maintain clearance from the DCS Central Registry.
• If driving is required, possession of a valid driver’s license and compliance with state driving requirements.

Skills

• Utilization Management practices and programs (including Prior Authorization).
• Leadership and organizational principles, oversight, and regulatory methodologies in managed care delivery systems.
• Knowledge of state legislative laws, regulations, and rules related to behavioral health care and child welfare.
• Pediatric care programs and clinical standards.
• Evidence-based criteria and principles of managed care, AHCCCS, and Medicaid.
• Direct management and coaching.
• Prioritizing responsibilities and managing time effectively to meet deadlines.
• Proficiency in Microsoft Office (Word, Excel, PowerPoint).
• Analytical and decision-making skills.
• Clinical problem-solving and troubleshooting.
• Strong verbal and written communication and presentation skills.
• Ability to meet deadlines, lead cross-functional teams, and coordinate activities.
• Strategic planning and implementation for Medical Management.
• Navigating information systems and staying up-to-date on clinical criteria and AHCCCS policies/procedures.
• Representing DCS within the community and state regarding health issues for children/youth in foster care.

Pay

$90,200.24 - $95,000.05 annually.

Benefits

• Affordable medical, dental, life, and short-term disability insurance plans.
• Top-ranked retirement and long-term disability plans.
• 10 paid holidays per year.
• Vacation time accrued at 4:00 hours bi-weekly for the first 3 years.
• Sick time accrued at 3:42 hours bi-weekly.
• Deferred compensation plan.
• Wellness plans.
• Paid Parental Leave program.
• Participation in the Arizona State Retirement System (ASRS) with enrollment eligibility after 27 weeks of employment.