Utilization Claims Review Nurse

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POST DATE 9/8/2016
END DATE 10/9/2016

Health Choice Phoenix, AZ

Phoenix, AZ
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Entry Level (0 - 2 years)
High School Diploma or GED


JOB SUMMARY: The Utilization Claims Review Nurse reviews and analyzes medical record and claims data, utilizing and applying Interqual Acute/Sub-acute Care Criteria and DRG coding practices to determine if inpatient admissions, observation stays, and ancillary services meet criteria. This position also maintains current information on regulatory guidelines as they pertain to acute and sub-acute levels of care.

Job Responsibility:
Review medical records and claims data for acute and sub-acute levels of care:
*Review clinical information for accuracy
*Review level of care and location of services delivered
*Review itemized bill to ensure accurate billing
*Complete review within established time frames
*Update information in electronic claims system
*Utilize clinical skills, chart review, physician communication, and Interqual standards for approval of claim
*Initiate interdepartmental coordination to ensure quality and timely care for members
*Review air, ambulance and ground transportation claims
*Identify member s Third Party Liability coverage
Collect and screen data for clinical review:
*Review claims with clinical reviewer when criteria is not met
*Review clinical information and claims with Medical Director when clinical determination is necessary
*Update authorizations as directed by the Medical Director
Provide assistance to Utilization Review Nurses:
*Maintain information on members as required from hospitals
*Distribute information to UR Nurses

Expected Outcomes:
*Claim reviews are completed in a timely manner
*Appropriate level of care is confirmed
*Claims are paid within the identified time frame per contractual requirements
*Interdepartmental communication occurs to request and obtain additional information to complete claim review
*Members are identified with Third Party Liability coverage
*Authorizations updated in timely manner
*Members are in appropriate level of care according to criteria
*Documentation is complete and accurate so claim is reimbursed in timely manner

Health Choice exists to improve the health and well-being of the individuals we serve through our health plans, integrated delivery systems and managed care solutions. We strive to recruit and retain only the finest health care professionals with the highest levels of integrity, compassion and competency. If you are driven by your own personal commitment to these values and desire to work in a team-focused, collaborative and supportive environment while still being valued for your individual strengths Health Choice is the place for you.

Equal Opportunity Employer Minorities/Women/Veterans/Disabled

Professional Competencies (knowledge, skills, and abilities):

*Knowledge of medical terminology
*Medical Records and Coding
*Interqual Acute/Sub-acute criteria
*Knowledge of Medicare and Medicaid regulations and guidelines
*Knowledge of ICD-9/ICD-10 (when applicable)
*Knowledge of CPT and HCPCS codes

*Computer experience necessary
*Effective time management skills
*Effective interpersonal and communication skills

*Ability to use electronic medical record and claims systems
*Problem solving abilities
*Work cooperatively, positively, and collaboratively in an interdisciplinary team
*Work respectfully and positively with members
*Ability to manage multiple tasks and prioritize work tasks to adhere to deadlines and identified time frames.

High School Diploma or equivalent GED
Associates degree or Bachelor s degree from an accredited Nursing School preferred

At least one (1) year medical claims experience
At least one (1) year experience working in a medical environment, such as a hospital, medical office, health plan
Previous Medicaid/Medicare experience preferred

Certification and License:
Active, current, valid, unrestricted Arizona State Registered Nurse (RN) License or LPN

Job: Business Services/Medical Records
Primary Location: Arizona-Phoenix
Organization: Health Choice
Education Level: Associate's Degree/College Diploma
Employee Status: Full Time Benefit Eligible 36-40 hrs/wk
Work Schedule: Days