The role will be focused on the review and adjudication of the client 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims. The candidate will need a computer which client can set up remote desktop access. The role does not currently allow for Overtime but could be approved as the client has need. 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 client 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: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 TribalHealthcare delivery system nationally and locallyManaged care processesAcute nursing processes including assessment, planning, intervention, and evaluationInterQual CriteriaCCICoding: CPT, HCPCS, ICD-9Medical Claims ReviewStatistical analysisComputer data retrieval and inputInterpretation of governmental agenciesClient Rules and RegulationsCode of Federal RegulationsRequirements:Active RN License in AZBehavior Health experience, (Outpatient preferably)Skills:Organizational skills that result in prioritization of multiple tasksInterpretation of rules, laws and client policy pertaining to the client programGood written and communication skillsComputer skillsUtilization Review skillsMedical Claims Review skillsProducing work products with limited supervisionEffectively collaborating with people in positions of all levelsResearch and analysisTeam player and can work independentlyAbilities:Interpret and apply medical and claims policiesRead and interpret medical documentationEvaluate medical documentation for emergency criteria, medical necessity, correct CPT codingDetermine appropriate hospital levels of care and lengths of stayRespond to inquiries for UR/CPT coding decisionsMaintain data for monthly reportsWork independently with minimal supervisionAbility to work VirtuallyExperience Requirements:High school DiplomaPossession of a current license to practice as a registered nurse in AZ and experience in health care delivery systems.Preferred:Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.Notes:8:00am- 5:00pm 40hrs per week, (M-F, no weekends. No OT time).RemotePrimarily remote, however candidates may need to go onsite. Candidate may go onsite for training 1-2 times for training once starting position.
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