Medical Review Nurse
Division of Fee for Service Management (DFSM)
Job Location:
Address: 801 E. Jefferson Street, Phoenix, AZ 85034
This position has the potential to work from a Virtual Office (VO) setting based on the needs of the unit and at the discretion of leadership.
Posting Details:
Salary: $71,032
Grade: 22
Closing Date: Open until filled
Job Summary:
This position is responsible for timely and accurate claims review and adjudication to avoid penalties, establishing and maintaining records and reports, interacting with claims personnel for review and assessing adjudication of work process, recommending edits and revision of claim charges, review of system parameters, and medical necessity based on standard of care and in accordance with AHCCCS Rules, Regulations and Federal Guidelines.
This position may be asked to provide cross-division support including support of clinical administration in evaluating and approving or denying payment for medical and/or behavioral health care services through prospective, concurrent, and retrospective review; in additional to support of the monitoring of quality management and quality assurance of FFS providers, including on-site provider visits and monitoring of corrective action plans; in addition to support of prepayment review of clinical documentation for appropriateness of billing; in addition to care management support of FFS members.
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.
Job Duties:
Major duties and responsibilities include but are not limited to:
• Monitor, evaluate, and approve or deny payment of medical and/or behavioral healthcare services through prospective, concurrent, and retrospective review. Determine medical necessity based on standards of care, rules, regulations, policies and procedures governing the provision of covered services. Ensure timely and accurate claims or authorization reviews, including timely determination for emergency criteria and/or medical necessity criteria, appropriate level of care and/or length of stay, determination of correct revenue/CPT/HCPC coding, timely claims adjudication or timely issuance of authorization determinations. Interact with claims personnel for review and assessment of the adjudication work process, recommend system edits or need to revise claim charges, and review of system parameters.
• Interact with other internal and external stakeholders, including other department providers, and tribal stakeholders, as needed. Collaborate to improve compliance related to utilization management process standards, AHCCCS policies and procedures, and Federal and State rules and regulations.
• Evaluate, recommend action, and provide ongoing monitoring for program policy compliance and reporting of data related to FESP or specialty services such as Specialty DME, Exception NF Rates, negotiated rates, and Over Institutional Cost services.
• Confer with Utilization Review Coordinators from the Peer Review Organizations regarding admission, concurrent length of stay, appropriateness of services, and retrospective reviews.
• Maintain documentation files, prepares and submits system generated reports, extracts, analyses savings and trends for unit, division, and management.
• May be asked to provide cross division support in clinical administration, Quality Management/Quality Assurance, Care Management, and Prepayment Review, in which case primary percent of time would be transitioned to that task.
Knowledge, Skills & Abilities (KSAs):
Knowledge of:
• Principles of utilization review
• Utilization review protocols related to all member populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physically disabled, developmentally disabled, behavioral/mental health, tribal, and FESP
• Understanding of tribal and non-tribal health care delivery systems and mechanisms necessary for coordination and delivery of services
• Principles and current standards of practice for the delivery emergent and non-emergent medical and/or behavioral health care
• Alternative levels of care
• ICD10 Diagnosis Coding; DSM-IV/V; CPT procedure coding
• Medical technology computer data retrieval and input
• InterQual or Milliman review criteria
• CCI
• Interrelations of governmental agencies
• Medicaid and Medicare member populations
• Federal Regulations. State Statute, Rule, and policies applicable to AHCCCS programs
• AHCCCS and ALTCS program design and implementation, including case management functions and responsibilities, and funding source
• Familiarity with American Indian Tribes/programs and policy relative to IGA's and other related policies
Skill in:
• 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
• Public relations skills, interacting with statewide providers of healthcare services, public organizations, and social agencies
• Organizational skills for setting priorities; workload, and record keeping
• Intermediate computer skills to access and input member information
• Analytical ability to identify and correlate specific patterns, initiate investigations, submit findings and recommendations
• Strong Interpersonal skills in working with people of diverse cultures and socioeconomic backgrounds
Ability to:
• Proficiency in oral and written communication
• Teach and train
• Interpret clinical information and assess implications for treatment
• Negotiate competitive rates to maximize available funding for members' care
• Read, Interpret, and apply complex rules and regulations
• Independent decision making
• Work Virtual Office or Telecommute or both
• 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
Selective Preference(s):
Minimum: Possession of a current license to practice as a registered nurse in the State of Arizona and 3 year's 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.
Pre-Employment Requirements:
• Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency’s ability to reasonably accommodate any restrictions.
• Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.)
If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver’s License Requirements.
All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).
Benefits:
Among the many benefits of a career with the State of Arizona, there are:
• 10 paid holidays per year
• Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)
• Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child. Learn more about the Paid Parental Leave pilot program here.
• Other Leaves - Bereavement, civic duty, and military.
• A top-ranked retirement program with lifetime pension benefits
• A robust and affordable insurance plan, including medical, dental, life, and disability insurance
• Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)
• RideShare and Public Transit Subsidy
• A variety of learning and career development opportunities
By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.
Learn more about the Paid Parental Leave pilot program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page
Retirement:
Lifetime Pension Benefit Program
• Administered through the Arizona State Retirement System (ASRS)
• Defined benefit plan that provides for life-long income upon retirement.
• Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.
• Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).
Deferred Retirement Compensation Program
• Voluntary participation.
• Program administered through Nationwide.
• Tax-deferred retirement investments through payroll deductions.
Contact Us:
Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.
Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.
