Medical Review Nurse
Job Description
Job Description
NEED LOCAL ARIZONA RESIDENTS ONLY
Candidate will go onsite for training 1-2 times for training once starting position. Compliance Items:- Active RN License in state of Arizona
- Fingerprint Clearance Card - Needed before start date.
- Candidate needs to obtain their own laptop
Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal
Healthcare delivery system nationally and locally
Managed care processes
Acute nursing processes including assessment, planning, intervention, and evaluation
InterQual Criteria
CCI
Coding: CPT, HCPCS, ICD-9
Medical Claims Review
Statistical analysis
Computer data retrieval and input
Interpretation of governmental agencies
AHCCCS Rules and Regulations
Code of Federal Regulations
Organizational skills that result in prioritization of multiple tasks
Interpretation of rules, laws and agency policy pertaining to the AHCCCS program
Good written and communication skills
Computer skills
Utilization Review skills
Medical Claims Review skills
Producing work products with limited supervision
Effectively collaborating with people in positions of all levels
Research and analysis
Team player and can work independently Abilities:
Interpret and apply medical and claims policies
Read and interpret medical documentation
Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding
Determine appropriate hospital levels of care and lengths of stay
Respond to inquiries for UR/CPT coding decisions
Maintain data for monthly reports
Work independently with minimal supervision
Ability to work Virtual Office Preferred Skills
- Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.
- Active Fingerprint Clearance Card
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