Claims Clinical Documentation Reviewer

Arizona Department of Administration • Phoenix, AZ

1d • 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 supportive documentation submitted by provider organizations for billed medical, behavioral health, non-emergency medical transportation (NEMT), and other related Medicaid services. The reviewer applies knowledge of healthcare laws, policies, and practices at the state, federal, and AHCCCS levels to support compliance with contractual, regulatory, and statutory obligations for Fee-for-Service services.

The role monitors service utilization, conducts prepayment claims reviews and in-depth audits, and provides oversight and technical assistance. It gathers, organizes, and evaluates information from utilization data, case file reviews, and audits; coordinates with internal and external stakeholders; makes referrals as needed; participates in clinical staffing and claims-related meetings; and serves as a resource on medically necessary covered services. The position may work from a virtual office or telecommute based on unit needs and leadership discretion. 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 Behavioral Health Professional independent or associate license.
• Arizona driver’s license.
• Knowledge of service authorization concepts, principles, and strategies.
• Advanced knowledge of behavioral health service delivery systems 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 Levels I and II, 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 and 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 for working with people from diverse cultures and socioeconomic backgrounds.
• Skills in documentation, research, and reporting 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 telecommute.
• Successfully pass a fingerprint background check, prior employment verifications, and reference checks.
• Newly hired State employees must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Nice To Haves

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

Responsibilities

• Conduct daily prepayment claim reviews for medical necessity, appropriateness of services, quality of care, and common billing errors across a variety of treatment service types.
• Conduct in-depth audits, including independent reviews and analysis, preparing audit reports, and potentially presenting findings.
• Learn to use AHCCCS’s Prepaid Medical Management Information System (PMMIS) to process prepayment-reviewed claims.
• Participate in team meetings, huddle boards, and similar meetings to learn about process updates and internal policy changes.
• Facilitate team meetings or huddle boards on a rotating basis.
• Review claims information and supporting documents and approve or deny claims.
• Review clinical documentation submitted by provider organizations for billed medical and behavioral health services, applying relevant state, federal, and AHCCCS laws, policies, and practices.
• Participate in developing and delivering training to improve the prepayment claims review process.
• Participate in in-person clinical provider reviews and conduct provider on-site 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 service utilization and provide oversight and technical assistance to support compliance with contractual, regulatory, and statutory obligations.
• Gather, plan, organize, and evaluate information from utilization data, case file reviews, and audits; coordinate with stakeholders and make referrals as necessary.
• Participate in clinical staffing and claims-centered meetings as needed and serve as a resource for medically necessary covered services.

Benefits

• 10 paid holidays per year.
• Paid vacation and sick leave: 13 vacation days and 12 sick days per year, earned starting 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.
• A 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.
• Remote work options that may support work-life balance; remote work is a management option and may be terminated at the agency’s discretion.
• Voluntary tax-deferred retirement investments through the Deferred Retirement Compensation Program administered by Nationwide.
• Required participation in the Long-Term Disability and ASRS Retirement plans.

What This Job Offers

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