What are the responsibilities and job description for the Title: Claims Documentation Reviewer position at Arizona Health Care Cost Containment System?
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 :
Skills :
Abilities :
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 :
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 :
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.
