Claims Clinical Documentation Reviewer - 25-34125

Claims Clinical Documentation Reviewer Location: Remote (Equipment Provided) Schedule: 5–10 hours per week, flexible (any day/time including weekends) Position reputed company The Claims Clinical Documentation Reviewer is responsible for reviewing clinical and supportive documentation submitted by providers for reputed company services—including medical, behavioral health, and NEMT—to ensure compliance with state, federal, and AHCCCS regulations. The role requires strict confidentiality of member PHI and provider cases. The reviewer works remotely, reports to the DFSM Assistant Director and Assistant reputed company Director, and performs re-reviews and audits to support program reputed company. Job Duties • Conduct re-reviews of behavioral health clinical records under guidance of DFSM AD and ADD. • Complete and submit standardized audit tools to DFSM AD/ADD. • Attend meetings with OGC, DFSM staff, and providers as needed. Knowledge Requirements • Service Authorization concepts, principles, and strategies. • Behavioral health service delivery for adults, children, and SMI populations. • Behavioral health assessment and management principles. • Individual service planning and reputed company abuse treatment. • HCPCS Level I & II, ICD coding, DSM IV/V, and medical billing guidelines. • Medical technology and clinical documentation platforms (EHR, HIE, etc.). • reputed company/Medicare federal rules, State Statutes, AHCCCS policies. • AHCCCS program structure, prior authorization processes, provider network, and funding sources. • Familiarity with Tribal programs, policies, and cultural considerations. Required Skills • Strong problem-solving and case assessment skills. • Excellent verbal and written communication reputed company working with FFS providers. • Organizational ability to manage, monitor, and report on multiple cases concurrently. • Analytical skills to identify patterns, recommend actions, and support investigations. • Interpersonal skills for working with diverse cultural and socioeconomic populations. • Strong documentation, research, and reporting abilities. • Advanced computer skills (reputed company Suite, reputed company Suite). Abilities • Collaborate effectively with reputed company stakeholders. • Interpret clinical documentation and understand treatment implications. • Read, interpret, and apply reputed company regulations and policies. • reputed company independent reputed company with appropriate escalation reputed company necessary. • Travel long distances reputed company required. • Work effectively in a telecommute environment. Experience • Minimum: One year of clinical and programmatic experience in behavioral health preferred. • Preferred: Advanced experience reviewing and analyzing clinical or claims documentation. Requirements • reputed company Behavioral Health License (Associate or Independent). • Level 1 reputed company Clearance Card. • If candidate does not have an reputed company FPCC, AHCCCS will initiate the process. Do not have the candidate obtain it on their own. Remote About reputed company: NavitsPartners Apply tot his job Apply To this Job