Claims Medical Records Specialist

AHCCCS

Arizona Health Care Cost Containment System

Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Courage, Teamwork

The Arizona Health Care Cost Containment System (AHCCCS), Arizona's Medicaid agency, is driven by its mission to deliver comprehensive, cost-effective health care to Arizonans in need. AHCCCS is a nationally acclaimed model among Medicaid programs and a recipient of multiple awards for excellence in workplace effectiveness and flexibility.

AHCCCS employees are passionate about their work, committed to high performance, and dedicated to serving the citizens of Arizona. Among government agencies, AHCCCS is recognized for high employee engagement and satisfaction, supportive leadership, and flexible work environments, including remote work opportunities. With career paths for seasoned professionals in a variety of fields, entry-level positions, and internship opportunities, AHCCCS offers meaningful career opportunities in a competitive industry.

Come join our dynamic and dedicated team.

Division of Fee for Service Management (DFSM)

Claims Medical Records Specialist

Job Location:

Address: 801 E. Jefferson Street, Phoenix, AZ 85034

IN OFFICE POSITION

Posting Details:

Salary: $33,500

Grade: 15

Closing Date: Open Until Filled

Job Summary:

This position is responsible for processing claims that are pended and have to be adjudicated per agency policies and procedures. The position requests medical documentation from providers, looks for consent forms, reviews the history for duplicates or duplicate payments, ensures the system is appropriately processing claims, and identifies inappropriate billing patterns, when are then reported to our audit unit or to the agency's Fraud Unit for review. The position looks for third party liability and ensures that the documentation needed is included with submissions. The position reprocesses Prior Authorization claims, supplements and links documentation, and recoups and voids claims. This position is also responsible for multiple special projects related to claims processing and adjudication. This position also performs statewide research in systems regarding records. Turning paper documents into a digital copy using scanning equipment. Duties typically include managing and storing files on a computer, raising concerns and issues with the scanning equipment to technicians and inspecting the quality of output regularly. Daily task assignments are based on immediate business needs.

This position in an in office only, reporting to the Medical Records Manager.

Major duties and responsibilities include but are not limited to:

• Processes claims that are pended (adjudicates); including requests medical documentation from providers, looks for consent forms, EOBs and Third-Party Liability, reviews the history for duplicates or duplicate payments, identifies inappropriate billing patterns and forwards to appropriate unit, ensures medical documentation is included with submissions, supplements and links documentation, recoups and voids claims.

• Ensure the system is appropriately processing claims, identifies problems/issues and notifies appropriate parties for resolution, identifies inappropriate billing patterns which are then reported to the Audit Unit or to the Agency's Fraud Unit for review. Verifies eligibility of claims, using agency's policies and procedures, coordinates claims that have Third Party Liability. Re-processes Prior Authorization Claims.

• Files original scanned document images in accordance with established guidelines to ensure accurate filing and facilitate timely retrieval of information. Ensures quality control by reviewing scanned rejected documents to identify/rescan poor quality document images to make sure all images entered into the system meet established quality standards and resolves inconsistencies.

• Reviews and links scanned, faxed and on-line supplemental documents to the appropriate claim using agency systems. Re-routing of unprocessed mail to appropriate destination and writes, types, or enters information into computer via MS Word, MS Excel or other departmental systems, using keyboard, to prepare documents or reports.

• System routing and processing of incoming RightFax documents for Prior Authorization and Claims gatekeeper in accordance with established guidelines to ensure accurate routing.

• Lifts, open, sorts, batches by claim type into predetermined batch size and prepares various forms for scanning by removing staples, paper clips, etc. and repairing documents as needed.

• Scans documents transcribing from paper formats into computer files. Verifies data to ensure accuracy while appropriately formatting, making adjustments for paper size/weight, color of ink, paper color, etc., to ensure acceptable image quality, and maintaining an even workflow. Responsible for logging document numbers automatically assigned during scanning for future retrieval.

Knowledge, Skills & Abilities (KSAs):

Knowledge:

• AHCCCS Programs & Eligibility Groups

• Administrative Rules and Regulations and AHCCCS Policies and Procedures

• Auditing and analysis procedures to determine compliance with AHCCCS requirements

• Medical terminology, CPT codes, ICD9 codes, HCPCS codes and CDT codes

• Third party liability laws as apply to State and Federal programs Principles of medical pricing (i.e., DME equipment, drugs, multiple surgical procedures)

• Digital Imaging system and procedures

• Inputting Medical/Dental documents to be into the system

• Document sorting, batching, routing, and coding practices/procedures/guidelines

• Thorough knowledge of all aspects of claims processing

• PMMIS and Docuware

Skills:

• Intermediate computer skills

• Oral and written communication

• Interpret rules and regulations, policies and procedures

• Analyze reports

• Professional interpersonal relationships

• Analyze problems and develop action plans for correction

• Quality assurance skills to ensure effectiveness of final product

• Microsoft windows (Excel and Word) or comparable software

• Operate and run a scanner

Abilities:

• Determine a pattern or inappropriate billing, which may indicate fraud

• Analyze system issues, elevating concerns to management

• Know when to report problems/issues in adjudication and when to proceed on their own

• Maintain a predetermined production level

• Provide technical training as required

• Work in a fast-paced environment independently and as a team

• Communicate effectively verbally and in writing

• Speed and accuracy to meet performance measurements

• Learn and closely follow established policies, procedures and guidelines

Selective Preference(s):

Arizona Drivers License

Minimum: One year experience in insurance processing & computer experience.

Preferred: Experience working in adjudication and working knowledge of medical coding. Proficient in Microsoft Office and above

average WPM typing skills.

Pre-Employment Requirements:

• Successfully complete the Electronic Employment Eligibility Verification Program (E-Verify), applicable to all newly hired State employees.

• Successfully pass fingerprint background check, prior employment verifications and reference checks; employment is contingent upon completion of the above-mentioned process and the agency's ability to reasonably accommodate any restrictions.

• Travel may be required for State business. Employees who drive on state business must complete any required driver training (see Arizona Administrative Code R2-10-207.12.) AND have an acceptable driving record for the last 39 months including no DUI, suspension or revocations and less than 8 points on your license. If an Out of State Driver License was held within the last 39 months, a copy of your MVR (Motor Vehicle Record) is required prior to driving for State Business. Employees may be required to use their own transportation as well as maintaining valid motor vehicle insurance and current Arizona vehicle registration; however, mileage will be reimbursed.

If this position requires driving or the use of a vehicle as an essential function of the job to conduct State business, then the following requirements apply: Driver's License Requirements.

All newly hired State employees are subject to and must successfully complete the Electronic Employment Eligibility Verification Program (E-Verify).

Benefits:

Among the many benefits of a career with the State of Arizona, there are:

• 10 paid holidays per year

• Paid Vacation and Sick time off (13 and 12 days per year respectively) - start earning it your 1st day (prorated for part-time employees)

• Paid Parental Leave-Up to 12 weeks per year paid leave for newborn or newly-placed foster/adopted child (pilot program).

• Other Leaves - Bereavement, civic duty, and military.

• A top-ranked retirement program with lifetime pension benefits

• A robust and affordable insurance plan, including medical, dental, life, and disability insurance

• Participation eligibility in the Public Service Loan Forgiveness Program (must meet qualifications)

• RideShare and Public Transit Subsidy

• A variety of learning and career development opportunities

By providing the option of a full-time or part-time remote work schedule, employees enjoy improved work/life balance, report higher job satisfaction, and are more productive. Remote work is a management option and not an employee entitlement or right. An agency may terminate a remote work agreement at its discretion.

Learn more about the Paid Parental Leave pilot program here. For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Retirement:

Lifetime Pension Benefit Program

• Administered through the Arizona State Retirement System (ASRS)

• Defined benefit plan that provides for life-long income upon retirement.

• Required participation for Long-Term Disability (LTD) and ASRS Retirement plan.

• Pre-taxed payroll contributions begin after a 27-week waiting period (prior contributions may waive the waiting period).

Deferred Retirement Compensation Program

• Voluntary participation.

• Program administered through Nationwide.

• Tax-deferred retirement investments through payroll deductions.

Contact Us:

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by emailing careers@azahcccs.gov.

Requests should be made as early as possible to allow time to arrange the accommodation. The State of Arizona is an Equal Opportunity/Reasonable Accommodation Employer.