Claims Processor – Medical Review Nurse

Job Post: Claims Processor – Medical Review Nurse Req #: SOAZ 8321 Client: AHCCCS (DFSM) Location: 801 E Jefferson St, Phoenix, AZ 85034 (Local Only/Remote) Contract: Until 01/12/2026 Rate: $34/hr W2 (All Inclusive) or $38/hr 1099 Schedule: Monday–Friday, 8 AM – 5 PM (40 hours/week, no weekends, OT possible if approved) Compliance Items Candidate Resume • * Level 1 Fingerprint Clearance Card (FPCC) – If not active, AHCCCS will initiate, please do not obtain independently • Active RN License in the State of Arizona Job Description The Medical Review Nurse will be responsible for reviewing and adjudicating Federal Emergency Services (FES) 1500 claim forms. This includes coordination with medical providers for second-level reviews, evaluating claims against prior authorizations and UB claims, and applying medical necessity criteria. This position is remote, with AHCCCS providing computer setup and remote desktop access. Key Responsibilities Perform medical claims review/adjudication to determine emergency criteria, medical necessity, correct coding, level of care, and length of stay. • Prepare reports and analyze savings and trends. • Interact with other departments/providers as needed. • Conduct special research projects. • * Maintain accurate data for monthly reports. Knowledge & Skills Medical nursing practice, case management, and utilization review protocols. • Strong knowledge of AHCCCS rules/regulations, managed care processes, and healthcare delivery systems. • * Familiarity with InterQual Criteria, CCI, CPT, HCPCS, ICD-9 coding. Medical claims review and utilization review experience. • Strong organizational, communication, and collaboration skills. • * Ability to work independently and virtually with limited supervision. Requirements • Active RN License in the State of Arizona (Required) • Behavioral Health experience (Outpatient preferred) • High School Diploma • Fingerprint Clearance Card (to be initiated by AHCCCS if not active) Preferred Qualifications Experience in concurrent and retrospective review. • Knowledge of CCI, InterQual, HCPCS, and CPT coding. • Managed care medical review experience. • * CPT Coding Certification (a plus). Apply tot his job