RN - Medical Review Claims Processor
Phoenix, AZ 85034
$34.00 Per Hour - Weekly Pay
Hybrid Schedule: In-office twice a month
The role will be focused on the review and adjudication of Federal Emergency Services (FES) 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims.
Major duties and responsibilities include but are not limited to:
- Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the AHCCCS recipient.
- Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed.
- Performs special projects including but not limited to research projects.
Schedule:
- 8:00am- 5:00pm 40hrs per week, (M-F, no weekends. No OT time).
Knowledge:
- Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal
- Healthcare delivery system nationally and locally
- Managed care processes
- Acute nursing processes including assessment, planning, intervention, and evaluation
- InterQual Criteria
- CCI
- Coding: CPT, HCPCS, ICD-9
- Medical Claims Review
- Statistical analysis
- Computer data retrieval and input
- Interpretation of governmental agencies
- AHCCCS Rules and Regulations
- Code of Federal Regulations
Requirements:
- Active RN License in state of Arizona
- Behavior Health experience, (Outpatient preferably)
- Fingerprint Clearance Card
Skills:
- Organizational skills that result in prioritization of multiple tasks
- Interpretation of rules, laws and agency policy pertaining to the AHCCCS program
- Good written and communication skills
- Computer skills
- Utilization Review skills
- Medical Claims Review skills
- Producing work products with limited supervision
- Effectively collaborating with people in positions of all levels
- Research and analysis
- Team player and can work independently
Abilities:
- Interpret and apply medical and claims policies
- Read and interpret medical documentation
- Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding
- Determine appropriate hospital levels of care and lengths of stay
- Respond to inquiries for UR/CPT coding decisions
- Maintain data for monthly reports
- Work independently with minimal supervision
- Ability to work Virtually
Experience Requirements:
- Possession of a current license to practice as a registered nurse in the State of Arizona and experience in health care delivery systems.
Preferred:
- Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.
Job Type: Full-time
Pay: $34.00 per hour
Expected hours: No less than 40 per week
Benefits:
- Dental insurance
- Health insurance
- Vision insurance
Application Question(s):
- What is the best email to reach you?
- Are you open to working a hybrid schedule after training has been completed?
- How soon can you start?
- This is a contract to hire position with the State of Arizona. Are you open to working a contract to hire role?
License/Certification:
- RN License (Required)
- Fingerprint Clearance Card (Required)
Work Location: Hybrid remote in Phoenix, AZ 85034
