Medical Review Nurse

Job Description

Job Description

LOOKING FOR ARIZONA RESIDENTS ONLY

SOAZ - Req # 8321 - AHCCCS (DFSM) - Claims Processor - Medical Review Nurse (Local Only / Remote)

Closing Date & Time : 10 / 8 / 2025@ 3 PM

Compliance Items : 1. Candidate Resume

2. Level 1 Fingerprint Clearance Card - If the candidate does not have an active FPCC the AHCCCS Facility will need to initiate it. Please do not have them obtain on their own FPCC.

3. RN License in the state of AZ

Job Description :

• 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.

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 :

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

Requirements :

Active RN License in state of Arizona

Behavior Health experience, (Outpatient preferably)

Fingerprint Clearance Card - If the candidate does not have an active FPCC the AHCCCS Facility will need to initiate it.

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 Virtually

Experience Requirements :

High school Diploma

Possession of a current license to practice as a registered nurse in the State of Arizona and

experience in health care delivery systems.

Preferred :

managed care medical review experience. Certification in CPT Coding is a plus.