Registered Nurse – Medical Claims Reviewer (AHCCCS) Job Available in Phoenix Arizona

Registered Nurse – Medical Claims Reviewer (AHCCCS)
Location: Remote (Arizona Residents Only)
Schedule: Monday–Friday, 8:00 a.m.–5:00 p.m. (40 hrs/week, No weekends or OT)

Overview:
Seeking an experienced Registered Nurse to review and adjudicate Federal Emergency Services (FES) 1500 medical claims for AHCCCS. This role requires strong clinical judgment, claims review expertise, and attention to compliance with medical necessity and coding standards. Candidates must be comfortable working independently in a virtual environment.

Key Responsibilities:

• Review and adjudicate FES 1500 claim forms using industry standards.

• Evaluate emergency criteria, medical necessity, CPT/HCPC/revenue code accuracy, and appropriate levels of care.

• Conduct concurrent and retrospective reviews.

• Prepare analytical reports and identify trends or savings opportunities.

• Coordinate with medical providers for 2nd-level reviews and documentation clarification.

• Participate in special projects and research as assigned.

Requirements:

• Active RN license (State of Arizona).

• Behavioral Health experience (Outpatient preferred).

• Fingerprint Clearance Card (or ability to obtain—required before onboarding).

• Proficiency with CPT, HCPCS, ICD-9, InterQual, CCI, and medical claims review processes.

• Excellent communication, organizational, and analytical skills.

• Strong computer proficiency and ability to work remotely with limited supervision.

Preferred Qualifications:

• Experience in managed care medical review.

• Certification in CPT Coding.

• Familiarity with AHCCCS rules, regulations, and federal code.

Additional Details:

• No overtime currently allowed, though may be approved as needed.

• Candidates must have access to a computer; AHCCCS will provide remote desktop access setup.

• Knowledge Services and HRD will coordinate fingerprint background checks prior to onboarding.