Registered Nurse / Claims - Remote

Job DescriptionJob DescriptionMajor duties and responsibilities include but are not limited to :Performs medical claims review / adjudication using claims industry standards.Determines if a claim meetsemergency criteria, medical necessity, and / or correct revenue code / CPT / HCPC coding.Also determines if thelevel of care and length of stay is appropriate for the AHCCCS recipient.Prepares reports and analyzes savings and trends.Interacts with otherdepartments / providers as needed.Performs special projects including but not limited to research projects.Schedule :8 :00am- 5 :00pm 40hrs per week, (M-F, no weekends unless OT is requested).Knowledge :Medical nursing practice, medical case management protocols, quality managementand utilization reviewprotocols as related to all populations including Maternal and Child Health services,preventive health, familyplanning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physicaldisabled, developmentally disabled, behavioral / mental health, and TribalHealthcare delivery system nationally and locallyManaged care processesAcute nursing processes including assessment, planning, intervention, and evaluationInterQual CriteriaCCICoding :CPT, HCPCS, ICD-9Medical Claims ReviewStatistical analysisComputer data retrieval and inputInterpretation of governmental agenciesAHCCCS Rules and RegulationsCode of Federal RegulationsRequirements :Active RN License in state of ArizonaFingerprint Clearance Card - Needed before start date.Skills :Organizational skills that result in prioritization of multiple tasksInterpretation of rules, laws and agency policy pertaining to the AHCCCS programGood written and communication skillsComputer skillsUtilization Review skillsMedical Claims Review skillsProducing work products with limited supervisionEffectively collaborating with people in positions of all levelsResearch and analysisTeam player and can work independentlyAbilities :Interpret and apply medical and claims policiesRead and interpret medical documentationEvaluate medical documentation for emergency criteria, medical necessity, correctCPT codingDetermine appropriate hospital levels of care and lengths of stayRespond to inquiries for UR / CPT coding decisionsMaintain data for monthly reportsWork independently with minimal supervisionAbility to work Virtual OfficeExperience Requirements :High school DiplomaMinimum :Possession of a current license to practice as a registered nurse in the Stateof Arizona andexperience in health care delivery systems.Preferred :Experience in concurrent and retrospective review; CCI, lnterQual, HCPCSand CPT Coding;managed care medical review experience.Certification in CPT Coding is a plus.Company DescriptionAbout BCforward :Founded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world.Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.BCforward champions the power of human potential to help companies transform, accelerate, and scale.Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years.Our strong culture and clear values have enabled BCforward to become a market leader and best in class places to work.BCforward is an equal opportunity employer.Company DescriptionAbout BCforward :rnrnFounded in 1998 on the idea that industry leaders needed a professional service, and workforce management expert, to fuel the development and execution of core business and technology strategies, BCforward is a Black-owned firm providing unique solutions supporting value capture and digital product delivery needs for organizations around the world.Headquartered in Indianapolis, IN with an Offshore Development Center in Hyderabad, India, BCforward's 6,000 consultants support more than 225 clients globally.rnrnBCforward champions the power of human potential to help companies transform, accelerate, and scale.Guided by our core values of People-Centric, Optimism, Excellence, Diversity, and Accountability, our professionals have helped our clients achieve their strategic goals for more than 25 years.Our strong culture and clear values have enabled BCforward to become a market leader and best in class places to work.rnrnBCforward is an equal opportunity employer.. Experience: 3 years required