Claims Clinical Documentation Reviewer

Arizona Department of Administration • Phoenix, AZ

2d • $68,000 - $71,032 • Hybrid

About The Position

The Claims Clinical Documentation Reviewer works in the Division of Fee for Service (DFSM) and reports to the Prepayment Program Manager. The position reviews clinical and other supporting documentation submitted by provider organizations for billed medical, behavioral health, non-emergency medical transportation (NEMT), and related Medicaid services. The reviewer applies knowledge of applicable state, federal, and AHCCCS laws, policies, and practices to assess claims and support compliance with contractual, regulatory, and statutory obligations for Fee-for-Service services.

The role monitors utilization, conducts prepayment claims reviews, audits and case-file reviews, and gathers, organizes, and evaluates information from sources such as utilization data and audits. It coordinates with internal and external stakeholders, makes referrals as needed, participates in clinical staffing and claims-related meetings, and serves as a resource regarding medically necessary covered services. The position is based in Phoenix, Arizona, and may be eligible for a virtual office setting or telecommuting at leadership’s discretion and according to unit needs. State work, including remote work, must be performed within Arizona unless an exception is authorized in advance.

Requirements

• Two to three years of clinical and programmatic experience working with behavioral health service delivery systems.
• Quality Management and/or Compliance Certification in behavioral health, or an Arizona Licensed Nurse credential, or an Arizona independent or associate Behavioral Health Professional license.
• Arizona Driver’s License (selective preference).
• Knowledge of service authorization concepts, principles, and strategies.
• Advanced knowledge of the behavioral health service delivery system and the needs of children and individuals designated as SMI.
• Knowledge of behavioral health management and assessment, individual service planning, and substance abuse treatment.
• Knowledge of HCPCS Level I and II codes, ICD and DSM-IV/V coding, and medical billing guidelines.
• Knowledge of medical technology and computer data retrieval and input, including EHR and HIE systems.
• Knowledge of Medicaid and Medicare federal regulations, state statutes, rules, and policies applicable to AHCCCS programs.
• Knowledge of AHCCCS program design and implementation, prior authorization functions and responsibilities, provider networks, and funding sources.
• Familiarity with American Indian Tribes, programs, and policy.
• Problem-solving skills, including identifying and evaluating issues and initiating appropriate action and case management assessment.
• Excellent verbal and written communication skills with Fee-for-Service providers.
• Organizational skills to coordinate, monitor, and report on multiple cases simultaneously.
• Analytical skills to identify and correlate patterns, initiate investigations, and submit findings and recommendations.
• Strong interpersonal skills when working with people from diverse cultures and socioeconomic backgrounds.
• Documentation, research, and reporting skills for data and trends.
• Strong computer skills, including Microsoft and Google Suite.
• Ability to collaborate with others toward mutually beneficial outcomes.
• Ability to interpret clinical information and assess implications for treatment.
• Ability to read, interpret, and apply complex rules and regulations.
• Ability to make independent decisions and recognize when to elevate a decision.
• Ability to drive long distances when required.
• Ability to work remotely.

Nice To Haves

• Advanced experience in clinical and/or claims supporting-documentation review and analysis.

Responsibilities

• Conduct daily prepayment claim reviews for medical necessity, service appropriateness, quality of care, and common billing errors across various treatment service types.
• Conduct in-depth audits, including independent reviews and analysis, preparing audit reports, and potentially presenting findings.
• Use the AHCCCS Prepaid Medical Management Information System (PMMIS) to process prepayment-reviewed claims.
• Review claims and supporting documents to approve or deny claims, applying relevant state, federal, and AHCCCS laws, policies, and practices.
• Participate in team meetings, huddle boards, and similar meetings to learn process updates and policy changes; facilitate team meetings or huddle boards on a rotating basis.
• Participate in developing and delivering training to improve the prepayment claims review process.
• Participate in in-person clinical provider reviews and on-site provider visits with DFSM Quality of Care units as needed.
• Participate in internal and external meetings as requested to collaborate and understand team and departmental workflows.
• Monitor over- and under-service utilization, provide oversight and technical assistance, and help ensure compliance with contractual, regulatory, and statutory obligations.
• Coordinate with internal and external stakeholders, make referrals as needed, and participate in clinical staffing and claims-centered meetings as needed.

Benefits

• 10 paid holidays per year.
• Paid vacation and sick leave: 13 vacation days and 12 sick days per year, beginning on the first day of employment and prorated for part-time employees.
• Paid parental leave of up to 12 weeks per year for a newborn or newly placed foster or adopted child, through a pilot program.
• Bereavement, civic duty, and military leave.
• State retirement program with lifetime pension benefits through the Arizona State Retirement System.
• Medical, dental, life, and disability insurance.
• Eligibility to participate in the Public Service Loan Forgiveness Program, subject to qualifications.
• Rideshare and public transit subsidy.
• Learning and career development opportunities.
• Optional full-time or part-time remote work schedule, subject to management discretion and agency policy.
• Voluntary deferred retirement compensation program administered through Nationwide.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed