Claim Review Nurse RN License Mostly remote AZ

S R INTERNATIONAL INC; Phoenix (AZ); Remote; USD 65,000 - 85,000; Full time

Job summary

A leading healthcare provider is seeking a Claim Review Nurse for a primarily remote position based in Arizona. The successful candidate will be responsible for reviewing and adjudicating medical claims while ensuring compliance with federal guidelines. Position requires an active RN license in Arizona and involves some coordination with medical providers. The role allows the flexibility of working from home with occasional on-site training, offering a chance to impact healthcare delivery significantly.

Qualifications

• Active RN License in Arizona required.
• Experience in health care delivery systems needed.
• Knowledge of CPT, HCPCS, ICD-9 coding preferred.

Responsibilities

• Review and adjudicate medical claims for Federal Emergency Services.
• Prepare reports and analyze trends.
• Coordinate with medical providers for reviews.

Skills

Organizational skills

Written and communication skills

Medical Claims Review skills

Research and analysis

Team player

Education

High school Diploma

Active RN License in state of Arizona

Job description

Claim Review Nurse RN License (Mostly remote- AZ)

S

S R INTERNATIONAL INC

Claim Review Nurse RN License (Mostly remote- AZ)

• Candidate needs to obtain their own laptop

· Primarily remote, Candidate may go onsite for training 1-2 times for training once starting position.

• Active RN License in state of Arizona

• Fingerprint Clearance Card - Needed before start date.

The role will be focused on the review and adjudication of Federal Emergency Services (FES) 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims. If a candidate has a fingerprint clearance card, that may help expedite the start date. The temp will need a computer which AHCCCS can set up remote desktop access. The role does not currently allow for Overtime but could be approved as the agency has need. For the questions above, HRD stated: We will conduct a fingerprint background check and Knowledge Services is aware of the requirement to have all candidates printed and results on hand with HRD before and contractor is onboarded.

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:

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

REQUIREMENTS:

Active RN License in state of Arizona

Fingerprint Clearance Card - Needed before start date.

SKILLS:

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

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

ABILITIES:

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

Ability to work Virtual Office

EXPERIENCE REQUIREMENTS:

High school Diploma

Possession of a current license to practice as a registered nurse in the State of Arizona and experience in health care delivery systems.

PREFERRED:

Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience.

Certification in CPT Coding is a plus.

REQUIRED SKILLS

Active RN License in state of Arizona

PREFERRED SKILLS

Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.