AHCCCS

Arizona Health Care Cost Containment System
Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork

The Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility.

AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry.

Come join our dynamic and dedicated team.

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 ser