Medical Review Nurse

Job Description

Job Description

NEED LOCAL ARIZONA RESIDENTS ONLY

Candidate will go onsite for training 1-2 times for training once starting position.

Compliance Items :

• Active RN License in state of Arizona
• Fingerprint Clearance Card - Needed before start date.
• Candidate needs to obtain their own laptop

SOAZ Posting ID # 5297 - Medical Review Nurse (Local Only / Mostly Remote / Onsite Trainings)

Skills Required :

Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral / mental health, and Tribal

Healthcare delivery system nationally and locally

Managed care processes

Acute nursing processes including assessment, planning, intervention, and evaluation

InterQual Criteria

Coding : CPT, HCPCS, ICD-9

Medical Claims Review

Statistical analysis

Computer data retrieval and input

Interpretation of governmental agencies

AHCCCS Rules and Regulations

Code of Federal Regulations

Organizational skills that result in prioritization of multiple tasks

Interpretation of rules, laws and agency policy pertaining to the AHCCCS program

Good written and communication skills

Computer skills

Utilization Review skills

Medical Claims Review skills

Producing work products with limited supervision

Effectively collaborating with people in positions of all levels

Research and analysis

Team player and can work independently

Abilities :

Interpret and apply medical and claims policies

Read and interpret medical documentation

Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding

Determine appropriate hospital levels of care and lengths of stay

Respond to inquiries for UR / CPT coding decisions

Maintain data for monthly reports

Work independently with minimal supervision

Ability to work Virtual Office

Preferred Skills