Job Description


  • 520101
  • Full-time


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.

Medical Review Nurse

Job Location:

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

Posting Details:

Closing Date: Open until filled 

Salary: $69,000 - $71,032

Grade: 22

Must reside in the state of Arizona

This position may be eligible for part-time/full-time remote work (including virtual office arrangement).

Job Summary:

The Division of Fee For Service Management is looking for a highly motivated individual to join our team as a Public Health Nurse Consultant/ Medical Review Nurse. This position is responsible for timely and accurate claims review and adjudication to avoid penalties, establishing, and maintaining records and reports, interacting with claims personnel for review and assessing adjudication work process, recommending edits, and recommending the need for revising claim charges, review of system parameters in accordance with AHCCCS Rules, Regulations, and Federal Guidelines. This position has the potential to work from a Virtual Office (VO) setting based on the needs of the unit and at the discretion of leadership.

Job Duties:

Major duties and responsibilities include but are not limited to:

? Performs medical claims review/adjudication using claims industry standards. Determines if a claim meets emergency criteria, medical necessity, and/or correct revenue code/CPT/HCPC coding. Also determines if the level of care and length of stay is appropriate for the AHCCCS recipient.
? Prepares reports and analyzes savings and trends. Interacts with other departments/providers as needed.
? Performs special projects including but not limited to research projects.

Knowledge, Skills & Abilities (KSAs):

? Medical nursing practice, medical case management protocols, quality management and utilization review protocols as related to all populations including Maternal and Child Health services, preventive health, family planning, sterilization, and pregnancy termination, EPSDT, acute, LTC, chronic long-term elderly and physical disabled, developmentally disabled, behavioral/mental health, and Tribal.
? Coding: CPT, HCPCS, ICD-9
? AHCCCS Rules and Regulations

? Organizational skills that result in prioritization of multiple tasks
? Interpretation of rules, laws and agency policy pertaining to the AHCCCS Program
? Medical Claims Review skills

? Interpret and apply medical and claims policies
? Read and interpret medical documentation
? Evaluate medical documentation for emergency criteria, medical necessity, correct CPT coding

Selective Preference(s):

? Possession of a current license to practice as a registered nurse in the State of Arizona and 3 years’ experience in health care delivery systems.
? Experience in concurrent and retrospective review; CCI, lnterQual, HCPCS and CPT Coding; managed care medical review experience. Certification in CPT Coding is a plus.

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 is 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).


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)
* 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.

For a complete list of benefits provided by The State of Arizona, please visit our benefits page


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
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.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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