Claims Processor - Medical Review Nurse

Talent Software Services; Phoenix (AZ); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading company in healthcare services is seeking a Medical Claims Reviewer to adjudicate Federal Emergency Services claims. This role involves analyzing claims for medical necessity and coordinating with medical providers. Candidates must have an active RN license in Arizona and possess strong organizational and communication skills. This position offers a primarily remote work environment with occasional onsite training.

Qualifications

• Active RN License in Arizona is required.
• Experience in health care delivery systems is needed.
• Knowledge of medical coding and claims review is preferred.

Responsibilities

• Perform medical claims review/adjudication using claims industry standards.
• Prepare reports and analyze savings and trends.
• Interact with other departments/providers as needed.

Skills

Organizational skills

Medical Claims Review skills

Research and analysis

Good written and communication skills

Team player

Education

High school Diploma

Active RN License in Arizona

Job description

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. 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 onboarding.

Major duties and responsibilities include but are not limited to :

1. 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.
2. Prepares reports and analyzes savings and trends. Interacts with other departments / providers as needed.
3. Performs special projects including but not limited to research projects.

Schedule :

• 8:00am - 5:00pm, 40hrs per week, (M-F, no weekends unless OT is requested).

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, 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
• 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 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 Arizona
• Experience in health care delivery systems.

Preferred :

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

Candidate Requirements :

• Candidate needs to obtain their own laptop
• Primarily remote, however candidates may need to go onsite. Candidate may go onsite for training 1-2 times once starting position.