Claims Medical Review Nursing Consultant

| AHCCCS *Arizona Health Care Cost Containment SystemAccountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, TeamworkThe Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility.AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. 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 variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities 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 North 18th Avenue Phoenix, Arizona 85007 #### This position may offer the ability to work remotely within Arizona based upon the department's needs and continual meeting of expected performance measures. #### All AHCCCS Employees must reside within the state of Arizona. | Posting Details: | | --- | #### Starting salary at $71,032 and may be increased based on experience and qualifications. #### FLSA Status: Exempt #### Grade: 22 #### Closing Date: Open until filled | Job Summary: | | --- | The position is responsible for monitoring, evaluating and approving or denying payment of medical and/or behavioral healthcare services through prospective, concurrent, 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 State of Arizona 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 able to work remotely in their homes, in offices, and in hoteling spaces. All work, including remote work, should be performed within Arizona 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 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, Skills & Abilities (KSAs): | | --- | **Knowledge of:** • 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 **Skill in:** • Organizational skills that result in prioritization…