Claims Medical Review Consultant

Arizona Department of Administration • Phoenix, AZ

8d • Remote

About The Position

The position is responsible for monitoring, evaluating and approving or denying
payment of medical and/or behavioral healthcare services through prospective,
concurrent, and retrospective review for the Fee for Service population. The
position determines medical necessity based on standards of care, rules,
regulations, policies and procedures governing the provision of covered
services.

The State of Arizona strives for a work culture that affords employees
flexibility, autonomy, and trust. Across our many agencies, boards, and
commissions, many State employees participate in the State’s Remote Work Program
and are able to work remotely in their homes, in offices, and in hoteling
spaces. All work, including remote work, should be performed within Arizona
unless an exception is properly authorized in advance.

Requirements

• 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
• 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
• 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
• Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher) and 3 years of relevant healthcare experience.
• May require a valid Arizona Driver License for travel-related duties.
• Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions.
• Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.)
• All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Nice To Haves

• Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care
• Knowledge of population served.

Responsibilities

• 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.

Benefits

• 10 paid holidays per year
• Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)
• Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child.
• Other Leaves - Bereavement, civic duty, and military.
• A top-ranked retirement program with lifetime pension benefits
• A robust and affordable insurance plan, including medical, dental, life, and disability insurance
• Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)
• RideShare and Public Transit Subsidy
• A variety of learning and career development opportunities

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 501-1,000 employees