Claims Clinical Documentation Reviewer

Claims Clinical Documentation Reviewer

Schedule:

5-10 hours per week. Resource can work any day of the week they are available and any time including weekends if they prefer. Remote position. Equipment is provided by facility.

Base pay: $50.00/hr - $52.00/hr.

Reports to the DFSM Assistant Director and Assistant Deputy Director.

• No overtime offered.
• Review clinical and supportive documentation submitted by providers for Medicaid services (medical, behavioral health, NEMT, etc.) to ensure compliance with state, federal, and AHCCCS regulations.
• Maintain confidentiality regarding member PHI and provider cases.
• Potential to work from a Virtual Office (VO).
• Conduct re-reviews of behavioral health clinical records under the oversight of the DFSM AD and ADD.
• Complete and submit standardized audit tools to DFSM AD and ADD.
• Attend meetings with OGC, DFSM staff, and providers as needed.

• One year of clinical and programmatic experience working with the behavioral health service delivery systems preferred.
• Advanced experience in clinical and/or claims supportive documentation review and analysis preferred.
• Behavior Health License, associate or independent in the ***.
• Level 1 Fingerprint Clearance Card required. If the candidate does not have an active FPCC the AHCCCS Facility will need to initiate it. Do not obtain on own FPCC.

• Service Authorization concepts, principles, and strategies.
• Advanced knowledge of the behavioral health service delivery system and the needs of children and 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.

• 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.

• 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.