Claim Review Nurse RN License (Mostly remote- AZ)
Full Time • Fully Remote - US
Job Description
• Candidate needs to obtain their own laptop
· Primarily remote, Candidate may go onsite for training 1-2 times for training once starting position.
• Active RN License in state of Arizona
• Fingerprint Clearance Card - Needed before start date.
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.
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
- Fingerprint Clearance Card - Needed before start date.
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
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:
Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience.
Certification in CPT Coding is a plus.
REQUIRED SKILLS
Active RN License in state of Arizona
PREFERRED SKILLS
- Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.
- Active Fingerprint Clearance Card
This is a remote position.
Compensation: $30.00 - $35.00 per hour
About SR International INC.
SR International has been a leading name among the IT consulting companies with offices in US and India. For past 16 years, our industry experience and domain knowledge have enabled us to provide innovative solutions to our customers.
Who We Are
Who We Are
We Are Leading IT Based Solution Providers
Today, the world of business information represents the realization of our collective efforts toward improving the future. Held only by the limits of our imagination, the business world is accelerating at an ever-increasing pace. Imagine a better way of doing business, of implementing the perfect software, of refining practice or business integration. All it takes are benchmark standards in service, support, and technical know-how, which have been our bread and butter.
Our Vision.
Our Vision.
Established in 2002, SR International Inc is one of the fastest growing and reputed provider of Information Technology Services and Solutions in the USA. Since our inception, we have been a trusted IT partner for our clients. We take pride in our highly skilled IT Resources and unique engagement model. We have been consistently delivering on our promises as a high-performance team. Our expertise in Cloud Computing, Mobility, Web Technologies, ERP and CRM are second to none. Our industry-leading flagship product iMathSmart is re-defining math learning experience for school students.
Career At SR International
At SR International, we treat our consultants like family. Our business and our reputation have been built and maintained by quality resources working onboard, so it’s important for us to maintain the quality resource pool.
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