Claims Clinical Documentation Reviewer

Claims Clinical Documentation Reviewer Division of Fee for Service (DFSM) Job Location Address: 150 North 18th Avenue Phoenix, Arizona 85007. This position may work from a Virtual Office (VO) setting or telecommute depending on unit needs and leadership discretion. 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. The role applies knowledge of healthcare State, Federal, and AHCCCS laws, policies, and practices to ensure compliance with contractual, regulatory, and statutory obligations for a variety of Fee‑for‑Service services. Tasks include monitoring utilization, conducting prepayment claims reviews, providing oversight and technical assistance, gathering, planning, organizing, and evaluating information from multiple sources, and coordinating with stakeholders. The State of Arizona provides a work culture that affords employees flexibility, autonomy, and trust. Remote work is available within Arizona subject to prior authorization. Responsibilities 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, including in‑depth audits, independent reviews, analysis, audit reports, and presentation of findings. Become proficient in using the AHCCCS information system, Prepaid Medical Management Information System (PMMIS), to process pre‑payment reviewed claims. Participate in team meetings, huddle boards, and similar meetings 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 supporting documents to approve or deny claims; review clinical documentation submitted by provider organizations in support of billed medical and behavioral health services, applying knowledge of State, Federal, and AHCCCS laws, policies, and practices. Participate in the development and delivery of trainings related to improving the overall prepayment claims review process. Participate in on‑site clinical provider reviews by conducting provider on‑site visits with the DFSM Quality of Care units as needed, and attend internal and external meetings to collaborate and ensure full understanding of team and departmental workflows. Provide monitoring and technical assistance to ensure compliance with contractual, regulatory, and statutory obligations for a variety of Fee‑for‑Service services. Coordinate with external and internal stakeholders as needed, make referrals, and participate in clinical staffing and related claims‑center meetings. 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 Preferences Arizona Driver's License Minimum Requirements 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 Requirements 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 the position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then Driver’s License Requirements apply All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E‑Verify) Benefits 10 paid holidays per year Paid Vacation and Sick time off (13 and 12 days per year respectively); start earning from 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 Option of full‑time or part‑time remote work schedule to improve work/life balance and job satisfaction; remote work is a management option and not an entitlement Retirement Lifetime Pension Benefit Program – administered through the Arizona State Retirement System (ASRS); defined benefit plan that provides lifelong 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 Deferred Retirement Compensation Program – voluntary participation; administered through Nationwide; tax‑deferred retirement investments through payroll deductions Equal Opportunity & Accommodations 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. #J-18808-Ljbffr