Medical Claim Reviewer -

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POST DATE 9/12/2016
END DATE 10/23/2016

AppleOne Phoenix, AZ

Phoenix, AZ
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Required Licenses/Certifications
Min Salary
Max Salary
Salary Unit
per year


Founded in 1996, we are an enterprise organization in healthcare industry.

We are in need of quality Medical Claim Reviewer. Work location can be in Phoenix or Tempe. Regular full-time daytime schedule Monday ? Friday. Hourly rate is $15 ? 25 DOE. Background check and drug test required.

Job Summary

Conducts retrospective review of behavioral health or medical/surgical claims for inpatient and outpatient services. Applies clinical, coding and processing knowledge to conduct review and process claims. Compiles information necessary to prepare cases program payment. Ensures adherence to program benefits as authorized. Provides clinical and coding-related information to medical director, providers, peer reviewers, Claims Administration, Program Integrity, Quality Management and the claims subcontractor as needed. Advises clinical and non-clinical staff on claims and coding questions.

o Conducts medical claims review using current claims processing guidelines and established clinical criteria e.g. CDST and policy keys, to evaluate medical necessity, appropriateness of care and program benefits, exclusions and limitations.
o Validates medical determinations through research of resources including regulatory manuals, computer files and documentation.
o Prepares cases program payment or medical director review as indicated.
o Validates all appropriate data is supplied with program invoice.
o Reviews claim data for process improvements related to all aspects of claims payment
o Ensures contract compliance for timelines regarding resolution of medical claims.
o Consistently meets medical claims processing quotas.
o Identifies and reports any potential quality or fraud issues to management, Quality Management or Program Integrity as needed.
o Provides support regarding clinical and coding questions.
o Regular and reliable attendance is required.

Education & Experience


o 2+ years claims review experience
o Knowledge of Behavioral health claims review
o Claim coding experience

Technical Skills

Thorough knowledge of policies and procedures, Managed Care concepts and medical terminology. Proficient with claim and coding tools such as Supercoder, Clinical Decision Support Tool, Current Procedural Terminology, Health Care Financing Administration Common Procedure Coding System, and American Dental coding. Ability to meet or exceed production standards in compliance with contract
We are an equal employment opportunity employer and will consider all qualified candidates without regard to disability or protected veteran status.