Claims 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 Documentation Reviewer

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 or may Telecommute based on the needs of the unit and at the discretion of leadership.

Posting Details:

Salary: $36,000 - $38,000 

Grade: 17

Closing Date: Open until filled

Job Summary:

Claims Documentation Reviewer reports to the Prior Authorization Manager and is responsible for reviewing supportive documentation, submitted by provider organizations, in support of billed NEMT 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. 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 transportation pre-payment review centered meetings as needed, serve as a resource for medically necessary covered services.

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:
• Conduct NEMT Pre-Payment Claim Reviews for medical necessity, appropriateness of services, quality and common billing errors, for a variety of service types, on a daily basis using the Prepaid Medical Management System (PMMIS) to process pre-payment reviewed claims.
• Conduct in-depth audits, involving independent reviews and analysis, formulation of an audit report and possible presentation of findings.
• Actively review claims information and its supportive documents, including NEMT trip ticket documentation to either approve or deny a claim. Review documentation submitted by provider organizations in support of billed NEMT services by applying knowledge of healthcare State, Federal, and AHCCCS laws, policies, and practices.
• 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.
• Participate in the development and delivery of trainings relating to the improvement of the overall NEMT pre-payment review process.
• Participate in internal and external meetings as requested to collaborate with others and ensure full understanding of team and departmental work flows.

Knowledge, Skills & Abilities (KSAs):

Knowledge:
• AHCCCS Rules and Regulations
• AHCCCS Claims Policies and Procedures
• AHCCCS Prior Authorization System
• Medical Terminology
• Concepts of research and analysis
• ICD9, CPT, HCPC Coding
• Medicare and TPL insurance
• Types of members eligibility & covered services in relation to the type of AHCCCS eligibility
• Specific geography of Arizona & New Mexico

Skills:
• Research and analysis
• Produce reports to management
• Maintain statistical reports
• Verbal and written communication
• Organizational skills
• Strong computer skills
• Good interpersonal skills

Abilities:
• Learn AHCCCS’ Fee for Service Provider Network
• Learn proper coding of diagnosis and appropriate types of transportation
• Formulate recommendations for process improvement
• Work on multiple tasks simultaneously
• Prioritize tasks to keep current
• Know when to work independently and when to elevate an issue/concern
• Ability to work Virtual Office, Telecommute or both

Selective Preference(s):

Minimum: Three years responsible administrative experience; or a Bachelor's degree in a field appropriate to the assignment from an accredited college or university and one year of the required experience.

Preferred: Preference will be given to candidates with experience in a healthcare environment. 1 year experience in Transportation, Claim’s Review or Prior Authorization. Advanced experience in NEMT and/or claims supportive documentation review and analysis.

Pre-Employment Requirements:

• Successfully complete the Electronic Employment Eligibility Verification Program (E-Verify), applicable to all newly hired State employees.
• 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.) AND have an acceptable driving record for the last 39 months including no DUI, suspension or revocations and less than 8 points on your license. If an Out of State Driver License was held within the last 39 months, a copy of your MVR (Motor Vehicle Record) is required prior to driving for State Business. Employees may be required to use their own transportation as well as maintaining valid motor vehicle insurance and current Arizona vehicle registration; however, mileage will be reimbursed.

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 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.

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