Summary:
The Registered Nurse will utilize standard criteria to review post-service and prepayment reviews of Outpatient Behavioral Health claims. The nurse will utilize HCPC Codes to ensure claims are being charted for correct processing of Arizona Medicaid requirements.
Responsibilities:
- Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
- Identifies and reports quality of care issues.
- Assists with Complex Claim review including DRG Validation, Itemized Bill Review, Appropriate Level of Care, Inpatient Readmission, and any opportunity identified by the Payment Integrity analytical team; requires decision making pertinent to clinical experience
- Documents clinical review summaries, bill audit findings and audit details in the database
- Provides supporting documentation for denial and modification of payment decisions
- Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of client policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
- Identify problems or needed changes, recommends resolution, and participates in quality improvement efforts.
- Provide accurate documentation.
- Maintain and enhance relationships between the business and the provider community.
Required Qualifications:
- Active Registered Nurse (RN) license to practice in the state of Arizona or a Compact License.
- 2+ years of clinical Behavioral Health experience (acute care hospital or Outpatient Clinic setting)
- 2+ years chart review experience (UM/UR, clinical review, quality review)
- Minimum 1 year of experience working remotely.
- Behavioral Health Claims review (post-payment and prepayment)
- Working knowledge of outpatient BH HCPCs codes (ex. H0004, H2017, S9480, etc.)
- Strong computer skills using tools like MS Teams, Sharepoint, Office, EMR, etc…
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