Claims Medical Review Nursing Consultant

Arizona Department of Administration • Phoenix, AZ

4d • Hybrid

About The Position

The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry. Come join our dynamic and dedicated team. This position may offer the ability to work remotely within Arizona based upon the department's needs and continual meeting of expected performance measures. All AHCCCS Employees must reside within the state of Arizona. Starting salary at $71,032 and may be increased based on experience and qualifications. 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

• 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.
• 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.
• 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