Claims Medical Review Nursing Consultant

State of Arizona Phoenix, AZ, US

AHCCCS

Arizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork

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.

Claims Medical Review Nursing Consultant

Division of Fee for Service Management (DFSM)

Job Location:

Address: 150 North 18th Avenue Phoenix, Arizona 85007

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.

Posting Details:

Starting salary at $71,032 and may be increased based on experience and qualifications.

FLSA Status: Exempt

Grade: 22

Closing Date: Open until filled

Job Summary:

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.

Major duties and responsibilities include but are not limited to:
• 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.

Knowledge, Skills & Abilities (KSAs):

Knowledge of:
• 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

Skill in:
• 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

Ability to:
• 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

Selective Preference(s):

Minimum: 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.

Preferred: Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served.

Pre-Employment Requirements:

• 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.)

If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements.

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Benefits:

Among the many benefits of a career with the State of Arizona, there are:
• 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. Learn more about the Paid Parental Leave pilot program here.
• 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

By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.

Learn more about the Paid Parental Leave program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Retirement:

Lifetime Pension Benefit Program
• Administered through the Arizona State Retirement System (ASRS)
• Defined benefit plan that provides for life-long income upon retirement.
• Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.
• Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).

Deferred Retirement Compensation Program
• Voluntary participation.
• Program administered through Nationwide.
• Tax-deferred retirement investments through payroll deductions.

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.
Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.

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