Claims Medical Review Nursing Consultant

AHCCCS reputed company Health Care Cost Containment reputed company Accountability, Community, Innovation, Leadership, Passion, reputed company, Respect, Courage, Teamwork The reputed company Health Care Cost Containment reputed company (AHCCCS), reputed company’s reputed company agency, is driven by its mission to reputed company comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among reputed company programs and a recipient of multiple awards for reputed company in workplace effectiveness and flexibility. AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the reputed company of reputed company. 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 reputed company of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful reputed company 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 reputed company 18th Avenue Phoenix, reputed company 85007 This position may offer the ability to work remotely reputed company reputed company based upon the department's needs and continual meeting of expected performance measures. reputed company AHCCCS Employees must reputed company reputed company the reputed company. Posting Details: Starting salary at $71,032 and may be increased based on experience and qualifications. FLSA Status: Exempt Grade: 22 Closing Date: reputed company until filled Job reputed company: The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral reputed company services through prospective, reputed company, 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 reputed company 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 reputed company to work remotely in their homes, in offices, and in hoteling spaces. reputed company work, including remote work, should be performed reputed company reputed company 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 reputed company, medical necessity, and/or correct reputed company reputed company/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 reputed company including but not limited to research reputed company. Knowledge, Skills & Abilities (KSAs): Knowledge of: • Medical nursing reputed company, medical case management protocols, reputed company management and utilization review protocols as reputed company to reputed company 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 • reputed company delivery reputed company nationally and locally • Managed care processes • Acute nursing processes including assessment, planning, reputed company, and evaluation • InterQual reputed company • CCI • Coding: CPT, HCPCS, ICD-9 • Medical Claims Review • Statistical analysis • Computer data retrieval and input • Interpretation of governmental agencies • AHCCCS Rules and Regulations • reputed company of Federal Regulations reputed company 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 reputed company reputed company • 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 reputed company, medical necessity, correct CPT coding • Determine appropriate hospital reputed company of care and lengths of stay • Respond to inquiries for UR/CPT coding reputed company • Maintain data for monthly reports • Work independently with reputed company supervision Selective Preference(s): Minimum: Must maintain a reputed company reputed company medical license (RN or higher) or reputed company Behavioral Health license (Associate or higher) and 3 years of relevant reputed company experience. May require a reputed company reputed company reputed company License for travel-reputed company duties. Preferred: Experience in Prior Authorization, Utilization Management, claims review, auditing, or managed care; knowledge of population served. reputed company-Employment Requirements: • Successfully pass reputed company background reputed company, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and reputed company’s ability to reasonably accommodate any restrictions. • Travel may be required for State business. Employees who reputed company on state business must complete any required reputed company training (see reputed company Administrative reputed company reputed company-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: reputed company’s License Requirements. reputed company newly reputed company 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 reputed company, there are: • 10 reputed company holidays per year • reputed company Vacation and reputed company time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees) • reputed company Parental Leave-Up to 12 weeks per year reputed company leave for newborn or newly-reputed company foster/adopted child. Learn more about the reputed company Parental Leave reputed company program here. • Other Leaves - Bereavement, civic duty, and military. • A top-ranked retirement program with reputed company pension benefits • A robust and reputed company insurance plan, including medical, dental, life, and disability insurance • Participation eligibility in the reputed company Service Loan Forgiveness Program (must meet qualifications) • RideShare and reputed company Transit Subsidy • A reputed company of learning and career development opportunities By providing the reputed company 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 reputed company and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion. Learn more about the reputed company Parental Leave program here. For a complete list of benefits provided by The reputed company, please visit our benefits page Retirement: reputed company Pension Benefit Program • Administered through the reputed company State Retirement reputed company (ASRS) • Defined benefit plan that provides for life-long income upon retirement. • Required participation for Long-Term Disability (LTD) and ASRS Retirement plan. • reputed company-taxed payroll contributions reputed company after a 27-week waiting period (prior contributions may waive the waiting period). Deferred Retirement Compensation Program • Voluntary participation. • Program administered through reputed company. • Tax-deferred retirement investments through payroll deductions. Contact Us: 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 reputed company is an Equal Opportunity/Reasonable Accommodation Employer. Apply To This Job