MEDICAL CLAIMS REVIEW NURSE

Medical Claims Review Nurse

Not Disclosed

Phoenix, AZ (100% Remote)

3.0 Months

Not Disclosed

Not Disclosed

Government - State

$-4/hour - $1/hour

Job Posted on (Oct 03, 2025)

Reference Number: RKAZPA31

Job Description

The role will be focused on the review and adjudication of the client 1500 claim forms. Some coordination will be required with medical providers for 2nd level reviews and evaluating against prior authorizations and UB claims. The candidate will need a computer which client can set up remote desktop access. The role does not currently allow for Overtime but could be approved as the client has need.

Major duties and responsibilities include but are not limited to:

Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the client recipient.

Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed.

Performs special projects including but not limited to research projects.

Knowledge

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

CCI

Coding: CPT, HCPCS, ICD-9

Medical Claims Review

Statistical analysis

Computer data retrieval and input

Interpretation of governmental agencies

Client Rules and Regulations

Code of Federal Regulations

Requirements

Active RN License in AZ

Behavior Health experience, (Outpatient preferably)

Skills

Organizational skills that result in prioritization of multiple tasks

Interpretation of rules, laws and client policy pertaining to the client 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 Virtually

Experience Requirements

High school Diploma

Possession of a current license to practice as a registered nurse in AZ and experience in health care delivery systems.

Preferred

Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.

Notes

8:00am- 5:00pm 40hrs per week, (M-F, no weekends. No OT time).

Remote

Primarily remote, however candidates may need to go onsite. Candidate may go onsite for training 1-2 times for training once starting position.

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status.