Claims Medical Review Nursing Consultant
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.
Requirements
- Must maintain a current Arizona medical license (RN or higher) or Arizona Behavioral Health license (Associate or higher)
- 3 years of relevant healthcare experience
- Successfully pass fingerprint background check, prior employment verifications and reference checks
- Employees who drive on state business must complete any required driver training
- All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
Nice To Haves
- May require a valid Arizona Driver License for travel-related duties.
- 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)
- 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
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
Associate degree
