Registered Nurse – Medical Claims Reviewer (AHCCCS)
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Job Location:
Phoenix, NM - USA
Monthly Salary:
Not Disclosed
Posted on:
30+ days ago
Vacancies:
1 Vacancy
Job Summary
Registered Nurse Medical Claims Reviewer (AHCCCS)
Location: Remote (Arizona Residents Only)
Schedule: MondayFriday 8:00 a.m.5:00 p.m. (40 hrs/week No weekends or OT)
Overview:
Seeking an experienced Registered Nurse to review and adjudicate Federal Emergency Services (FES) 1500 medical claims for AHCCCS. This role requires strong clinical judgment claims review expertise and attention to compliance with medical necessity and coding standards. Candidates must be comfortable working independently in a virtual environment.
Key Responsibilities:
Review and adjudicate FES 1500 claim forms using industry standards.
Evaluate emergency criteria medical necessity CPT/HCPC/revenue code accuracy and appropriate levels of care.
Conduct concurrent and retrospective reviews.
Prepare analytical reports and identify trends or savings opportunities.
Coordinate with medical providers for 2nd-level reviews and documentation clarification.
Participate in special projects and research as assigned.
Requirements:
Active RN license (State of Arizona).
Behavioral Health experience (Outpatient preferred).
Fingerprint Clearance Card (or ability to obtainrequired before onboarding).
Proficiency with CPT HCPCS ICD-9 InterQual CCI and medical claims review processes.
Excellent communication organizational and analytical skills.
Strong computer proficiency and ability to work remotely with limited supervision.
Preferred Qualifications:
Experience in managed care medical review.
Certification in CPT Coding.
Familiarity with AHCCCS rules regulations and federal code.
Additional Details:
No overtime currently allowed though may be approved as needed.
Candidates must have access to a computer; AHCCCS will provide remote desktop access setup.
Knowledge Services and HRD will coordinate fingerprint background checks prior to onboarding.
Key Skills
- EMR Systems
- Hospital Experience
- Acute Care
- ICU Experience
- Hospice Care
- Workers' Compensation Law
- Home Care
- Nursing
- Catheterization
- Critical Care Experience
- Medication Administration
- Tube Feeding
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