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…