Behavioral Health Quality Management Specialist

Behavioral Health Quality Management Specialist

Location: Phoenix, AZ
Position Type: Remote

Pay: $31.68

Position Overview

We are seeking an experienced Behavioral Health Quality Management Specialist to support behavioral health service delivery, quality management, compliance, and service authorization activities. This position requires a strong understanding of Arizona's behavioral health system, AHCCCS programs, Medicaid regulations, clinical documentation, and service authorization processes.

The ideal candidate will have clinical or programmatic experience in outpatient behavioral health, strong analytical and communication skills, and the ability to review clinical information, interpret regulations, coordinate with providers, and manage multiple cases independently.

Key Responsibilities

• Review and evaluate behavioral health services, clinical information, and supporting documentation to ensure compliance with applicable requirements.
• Support service authorization and prior authorization activities, including reviewing clinical information and assessing treatment needs.
• Apply knowledge of behavioral health service delivery systems, including services for children and individuals designated as Seriously Mentally Ill (SMI).
• Review individual service plans, behavioral health assessments, and substance abuse treatment documentation.
• Interpret and apply AHCCCS policies, Medicaid and Medicare regulations, state statutes, rules, and program requirements.
• Communicate and coordinate with Fee-for-Service (FFS) providers regarding service authorization, documentation, and program requirements.
• Identify trends, discrepancies, and potential compliance concerns through research, documentation review, and data analysis.
• Conduct appropriate follow-up, initiate investigations when necessary, and prepare findings and recommendations.
• Maintain accurate records, reports, and case documentation.
• Utilize electronic health records (EHR), health information exchanges (HIE), and other computer systems to retrieve, review, and enter information.
• Collaborate with internal teams and external providers to support quality outcomes and effective service delivery.

Required Qualifications

• Quality Management and/or Compliance Certification within the behavioral health field, OR an active Arizona Behavioral Health Professional license in good standing.
• Acceptable Arizona behavioral health licenses include:
• Licensed Associate Counselor (LAC) or Licensed Professional Counselor (LPC)
• Licensed Independent Addiction Counselor (LIAC) or Licensed Associate Addiction Counselor (LAAC)
• Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW)
• Licensed Associate Marriage and Family Therapist (LAMFT) or Licensed Marriage and Family Therapist (LMFT)
• Minimum of 2–3 years of clinical and/or programmatic experience working within behavioral health service delivery systems.
• Experience working in an outpatient behavioral health setting.
• Knowledge of behavioral health management, clinical assessment, individual service planning, and substance abuse treatment.
• Understanding of service authorization, utilization management, and behavioral health program requirements.
• Strong verbal and written communication, analytical, organizational, and problem-solving skills.
• Proficiency with Microsoft Office and Google Workspace applications.
• Ability to work independently, manage multiple assignments, and recognize when issues need to be escalated.

Preferred Qualifications

• Advanced experience reviewing and analyzing clinical documentation and/or claims supporting documentation.
• Knowledge of HCPCS Level I and II codes, ICD-10, DSM-IV/V coding, and medical billing guidelines.
• Familiarity with AHCCCS program design, provider networks, funding sources, and prior authorization functions.
• Knowledge of Medicaid and Medicare federal regulations and Arizona state policies applicable to AHCCCS programs.
• Experience with EHR and HIE systems.
• Familiarity with American Indian tribes, programs, and applicable policies.