Medical Review RN

Job Overview

The role will be focused on the review and adjudication of Federal Emergency Services (FES) 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims. If a candidate has a fingerprint clearance card, that may help expedite the start date. The temp will need a computer which AHCCCS can set up remote desktop access. The role does not currently allow for Overtime but could be approved as the agency has need. For the questions above, HRD stated : We will conduct a fingerprint background check and Knowledge Services is aware of the requirement to have all candidates printed and results on hand with HRD before and contractor is onboarded.

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.

Skills :

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 all levels

Research and analysis

Team player and can work independently

Abilities :

Interpret and apply medical and claims policies

Read and interpret medical documentation

Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding

Determine appropriate hospital levels of care and lengths of stay

Respond to inquiries for UR / CPT coding decisions

Maintain data for monthly reports

Work independently with minimal supervision

Ability to work Virtual Office