Outpatient Behavioral Health Claims Reviewer (Registered Nurse)

*MUST HAVE AZ NURSING LICENSE OR COMPACT NURSING LICENSE TO APPLY*

Fully remote - employee will work in their own timezone

Pay - $40-42/hr

Open to part time or full time candidates

Position: Outpatient Behavioral Health Claims Reviewer

Overview: The Outpatient Behavioral Health Claims Reviewer is tasked with performing pre-payment and post-service claims evaluations for various BH HCPCs codes to assess the necessity and appropriateness of services provided. The ideal candidate will meet the following qualifications:

Required Qualifications:

• Active AZ RN License or compact states license (preference for Arizona residents) OR an active LCSW or LMSW license in Arizona.
• Licensed behavioral health professionals must hold a Master's degree, be AZ licensed, and have experience with service billing processes.
• A minimum of 2 years of clinical experience in Behavioral Health (acute care hospitals, outpatient clinic settings, etc.).
• At least 2 years of experience in chart review (utilization management, clinical review, quality assurance, etc.).
• A minimum of 2 years of experience working remotely.

Preferred Qualifications:

• Experience with outpatient behavioral health claims review (both post-service and pre-payment).
• Familiarity with outpatient BH HCPCs codes (e.g., H0004, H2017, S9480, etc.).
• Proficiency in Microsoft Teams and SharePoint.

Position Details:

• This project is specifically focused on Arizona Medicaid-AHCCCS and CMS. Last year, discrepancies were identified concerning incorrect billing and service delivery for AHCCCS patients in Behavioral Health.
• Phoenix is not only the fifth most populous city in the U.S., but it also has a significant tribal community presence, with at least five tribes in the surrounding area-all of which are AHCCCS patients, facing a high demand for Mental Health and Substance Abuse/Detox services.
• The primary responsibility of this role is to review AHCCCS claims, both prior to payment and after services, to determine the legitimacy of the claims. Key questions include: Did the services occur? Were they billed and coded correctly?
• Nurse will be utilizing various AHCCCS-specific programs, in addition to Microsoft Office applications (such as Excel).
• Claims reviewed per day is approximately 12-18, though this may fluctuate.

Equipment provided - laptop, monitors, docking station