Claims Medical Records Specialist

1 week ago


Phoenix, United States State of Arizona Full time

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.

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