Claims Clinical Documentation Reviewer

Location: Remote (Equipment Provided)
Schedule: 5–10 hours per week, flexible (any day/time including weekends)

Position Summary

The Claims Clinical Documentation Reviewer is responsible for reviewing clinical and supportive documentation submitted by providers for Medicaid services—including medical, behavioral health, and NEMT—to ensure compliance with state, federal, and AHCCCS regulations. The role requires strict confidentiality of member PHI and provider cases. The reviewer works remotely, reports to the DFSM Assistant Director and Assistant Deputy Director, and performs re-reviews and audits to support program integrity.

Job Duties

• Conduct re-reviews of behavioral health clinical records under guidance of DFSM AD and ADD.

• Complete and submit standardized audit tools to DFSM AD/ADD.

• Attend meetings with OGC, DFSM staff, and providers as needed.

Knowledge Requirements

• Service Authorization concepts, principles, and strategies.

• Behavioral health service delivery for adults, children, and SMI populations.

• Behavioral health assessment and management principles.

• Individual service planning and substance abuse treatment.

• HCPCS Level I & II, ICD coding, DSM IV/V, and medical billing guidelines.

• Medical technology and clinical documentation platforms (EHR, HIE, etc.).

• Medicaid/Medicare federal rules, State Statutes, AHCCCS policies.

• AHCCCS program structure, prior authorization processes, provider network, and funding sources.

• Familiarity with Tribal programs, policies, and cultural considerations.

Required Skills

• Strong problem-solving and case assessment skills.

• Excellent verbal and written communication when working with FFS providers.

• Organizational ability to manage, monitor, and report on multiple cases concurrently.

• Analytical skills to identify patterns, recommend actions, and support investigations.

• Interpersonal skills for working with diverse cultural and socioeconomic populations.

• Strong documentation, research, and reporting abilities.

• Advanced computer skills (Microsoft Suite, Google Suite).

Abilities

• Collaborate effectively with internal and external stakeholders.

• Interpret clinical documentation and understand treatment implications.

• Read, interpret, and apply complex regulations and policies.

• Make independent decisions with appropriate escalation when necessary.

• Travel long distances when required.

• Work effectively in a telecommute environment.

Experience

• Minimum: One year of clinical and programmatic experience in behavioral health preferred.

• Preferred: Advanced experience reviewing and analyzing clinical or claims documentation.

Requirements

• Active Behavioral Health License (Associate or Independent).

• Level 1 Fingerprint Clearance Card.

  • If candidate does not have an active FPCC, AHCCCS will initiate the process. Do not have the candidate obtain it on their own.