We are seeking skilled Medicaid Claims Reviewers with a solid clinical Behavioral Health background to join our remote team. We are assisting AZ AHCCCS in identifying and addressing fraudulent claims related to Behavioral Health services.
Project Alignment
- Specifically aligned with AZ Medicaid-AHCCCS
- Addressing issues identified last year regarding incorrect billing and servicing of Behavioral Health services for AHCCCS patients
Key Responsibilities
- Review AHCCCS claims, both prepayment and post-service, to identify potential fraud
- Verify if the services were actually provided
- Ensure services were done, billed, or coded correctly
- Utilize AHCCCS-specific programs and Microsoft Office apps (e.g., Excel)
Population
- High frequency of Mental Health, Substance Abuse, and Detox services among AHCCCS patients
- Phoenix, the 5th most populated US city, has a significant tribal community presence with at least five surrounding the city
Workload
- Review approximately 12-18 claims per day (varies daily)
Team:
- Collaborate with a Director and Associate Project Director (both experienced nurses)
- Work alongside many other nurses from across the US on this project
Qualifications
- AZ RN License or compact state license (preference for those in AZ) OR active AZ LCSW or LMSW license
- Master's degree for licensed behavioral health professionals
- Minimum 2 years of clinical Behavioral Health experience
- Minimum 2 years of chart review experience (UM, clinical review, quality review, etc.)
Soft Skills
- General understanding of the changing healthcare environment
- Strong analytical and attention to detail skills
- Excellent communication and teamwork abilities
Schedule
- Monday to Friday, 8:00AM - 5:00PM