Claims Processor - Medical Review Nurse

TALENT Software Services; Phoenix (AZ); Remote; USD 60,000 - 90,000; Full time

Job summary

An established industry player is seeking a detail-oriented medical claims reviewer to ensure compliance with emergency criteria and coding standards. This role involves coordinating with medical providers and conducting thorough evaluations of claims. Candidates will engage in special projects, analyze trends, and prepare detailed reports. With a structured schedule and primarily remote work, this position offers a unique opportunity to contribute to healthcare delivery while maintaining a work-life balance. Join a team dedicated to quality management and make a meaningful impact in the healthcare sector.

Qualifications

• Active RN license required.
• Experience in healthcare delivery and claims review is essential.

Responsibilities

• Perform medical claims review/adjudication using industry standards.
• Prepare reports and analyze savings and trends.

Skills

Organizational skills

Rule/law interpretation

Communication

Computer proficiency

Utilization and claims review skills

Independent work capability

Collaboration

Research

Analysis

Education

High school diploma

Active RN license

Job description

The role will focus on reviewing and adjudicating Federal Emergency Services (FES) 1500 claim forms. Coordination with medical providers for second-level reviews and evaluation against prior authorizations and UB claims will be required. A fingerprint clearance card may expedite the start date. The temp will need a computer with remote desktop access set up by AHCCCS. Currently, overtime is not permitted but may be approved based on agency needs. HRD will conduct a fingerprint background check, and candidates must have results on hand before onboarding.

Major duties and responsibilities include but are not limited to:

1. Perform medical claims review/adjudication using industry standards, determining if claims meet emergency criteria, medical necessity, and correct coding (revenue code/CPT/HCPCS). Assess appropriateness of level of care and length of stay for AHCCCS recipients.
2. Prepare reports, analyze savings and trends, and interact with other departments/providers as needed.
3. Perform special projects including research tasks.

Schedule:

• 8:00 am - 5:00 pm, 40 hours/week, Monday to Friday. No weekends unless overtime is requested.

Knowledge:

• Medical nursing practice, case management protocols, quality management, and utilization review for various populations.
• Healthcare delivery systems, managed care processes, acute nursing processes, InterQual Criteria, CCI, coding (CPT, HCPCS, ICD-9), claims review, statistical analysis, data retrieval, governmental agency interpretation, AHCCCS rules, CFR.

Requirements:

• Active RN license in ***.
• Fingerprint Clearance Card (needed before start date).

Skills:

• Organizational skills, rule/law interpretation, communication, computer proficiency, utilization and claims review skills, independent work capability, collaboration, research, and analysis.

Abilities:

• Interpret and apply medical and claims policies, read and evaluate medical documentation, determine appropriate hospital care levels, respond to inquiries, maintain data, work independently, and work virtually.

Experience Requirements:

• High school diploma, current RN license, healthcare delivery experience.

Preferred:

• Experience in review processes, coding, managed care review, CPT certification is a plus.

Candidate Requirements:

• Own laptop, primarily remote work with possible onsite training 1-2 times.