Occupational Therapist

This position reports within the Division of Developmental Disabilities Quality Management Unit and conducts quality of care investigations pursuant to the contract with the Arizona Health Care Cost Containment System (AHCCCS). The role involves participating in investigations of member-centric and systemic quality of care concerns to ensure member health and well-being. The position requires conducting timely, thorough, member-centric, and systemic investigations for all division member quality of care issues and implementing vendor-specific corrective action plans using a standardized process.

• Make appropriate referrals to oversight and regulatory agencies.
• Participate in Care Concerns, Care Needed Today, and member issues as assigned.
• Maintain 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 elevate cases and/or trend concerns to QOC supervisor.

Skills

• Critical thinking and technological skills, including use of databases.
• Proficiency in Microsoft Office products, email, and electronic referral and verification sources.
• Ability to produce professional technical reports and letters.
• Research and analysis skills.
• Strong oral and written communication skills.
• Personal planning, organization, and time management.
• Medical chart review expertise.
• Understanding of the nursing process, including assessment, monitoring, and evaluation.
• Decision-making skills.
• Ability to critically analyze problems and develop effective plans for corrective action.

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.
• 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.

Physician Responsibilities

• Serve as the primary clinical reviewers and certify their cases.
• 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 Division's ECR process and templates.
• Evaluate complex needs, synthesize information from multiple sources, document reasoning clearly, and complete assignments within required timelines (48 hours from case assignment).
• Knowledge of pediatrics and adolescent and teenage development is essential.
• Experience with people with developmental disabilities, complex medical or behavioral needs, and interdisciplinary review is 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.
• Each case may take 1-3 hours for review and documentation.
• Turnaround time from receipt is 48 hrs.
• Additional time may be granted in extenuating circumstances, if records are needed, or if communication with the health care decision maker is required.

Required Education for All Roles

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

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 training will be provided if needed.