Claims Clinical Documentation Reviewer

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.

Claims Clinical Documentation Reviewer

Division of Fee for Service (DFSM)

Job Location:

Address: 150 North 18th Avenue Phoenix, Arizona 85007

This position has the potential to work from a Virtual Office (VO) setting or may Telecommute based on the needs of the unit and at the discretion of leadership.

Posting Details:

Salary: $68,000 - $71,032

Grade: 21

Closing Date: Open until filled

Job Summary:

Claims Clinical Documentation Reviewer reports to the Prepayment Program Manager and is responsible for reviewing clinical and/or supportive documentation, submitted by provider organizations, in support of billed medical, behavioral health, NEMT and other related Medicaid services by applying knowledge of healthcare State, Federal, and AHCCCS laws, policies, and practices. This position will provide monitoring and technical assistance to ensure compliance with contractual, regulatory, and statutory obligations for a variety of Fee-for-Service (FFS) services. Monitor over and under service utilization, conduct prepayment claims reviews, provide oversight and technical assistance, gather, plan, organize and evaluate information from multiple sources, including utilization data, case file reviews and audits. Coordinate with external and internal stakeholders as needed, make referrals as necessary, participate in clinical staffing and/or related claims centered meetings as needed, serve as a resource for medically necessary covered services.

Major duties and responsibilities include but are not limited to:

• Conduct Pre‑Payment Claim Reviews for medical necessity, appropriateness of services, quality of care and common billing errors, for a variety of treatment service types, on a daily basis. Conduct in-depth audits, involving independent reviews and analysis, formulation of an audit report and possible presentation of findings.
• Become efficient in utilizing the Arizona Health Care Cost Containment System (AHCCCS) information system called Prepaid Medical Management Information System (PMMIS), in order to process pre‑payment reviewed claims.
• Participate in team meetings, huddle boards and similar meetings, in order to learn about new process updates and internal policy changes. Facilitate a team meeting or huddle board, on a rotating basis.
• Actively review claims information and its supportive documents to either approve or deny a claim. Review clinical documentation submitted by provider organizations in support of billed medical and behavioral health services by applying knowledge of healthcare State, Federal, and AHCCCS laws, policies, and practices.
• Participate in the development and delivery of trainings relating to the improvement of the overall prepayment claims review process.
• Participate in, in‑person clinical provider reviews by conducting provider on‑site visits with the DFSM Quality of Care units as needed. Participate in internal and external meetings as requested to collaborate with others and ensure full understanding of team and departmental workflows.

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.

Knowledge, Skills & Abilities (KSAs):

Knowledge:

• Service Authorization concepts, principles, and strategies
• Advanced knowledge of the behavioral health service delivery system and the needs of children and the needs of individuals designated as SMI
• Principles of behavioral health management and assessment
• Individual service planning process and substance abuse treatment
• HCPCS codes Levels I & II and, knowledge of International Classification of Diseases, DSM IV/V coding and medical billing guidelines
• Medical technology, computer data retrieval and input, including EHR, HIE, etc
• Medicaid and Medicare Federal Regulations, State Statute, Rules, and Policies applicable to AHCCCS programs
• AHCCCS program design and implementation, prior authorization functions and responsibilities, provider network, and funding source
• Familiarity with American Indian Tribes, programs and policy

Skills:

• Problem solving identification, evaluation, and imitation of appropriate action and case management assessment
• Excellent verbal/written communication skills, with FFS Providers
• Organizational skills to coordinate, monitor and report on multiple cases simultaneously
• Analytical skills 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
• Documentation, research, and reporting of data and trends
• Strong computer skills including Microsoft and Google Suite

Abilities:

• Strong ability to collaborate with others for mutually beneficial outcomes
• Interpret clinical information and assess implications for treatment
• Read, interpret, and apply complex rules and regulations
• Independent decision making yet knowing when to elevate the decision
• Drive long distances when required
• Ability to work Telecommute

Selective Preference(s):

Arizona Driver's License

Minimum: Two to three years clinical and programmatic experience working with the behavioral health service delivery systems. Quality Management and/or Compliance Certification within the field of behavioral health, or Arizona Licensed Nurse, or Behavioral Health Professional (independent/associate license within AZ).

Preferred: Advanced experience in clinical and/or claims supportive documentation review and analysis.

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.

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 (pilot program).
• 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 View email address on click.appcast.io. 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.