Position Type: Contract | Duration: Approximately 1 Year
Schedule: 5 days per week | 40 hours per week
Work Arrangement: Remote/Offsite Eligible
$45-48/hour
Location: Phoenix, Arizona
The Medical Claims Review & Special Investigations Specialist is responsible for conducting detailed medical claims reviews, analyzing potential fraud, waste, and abuse (FWA), and ensuring claims are processed in accordance with applicable benefit plans, policies, guidelines, contracts, and regulatory requirements. This role requires strong analytical, investigative, clinical, and communication skills, as well as the ability to collaborate with internal departments, healthcare providers, government agencies, and other stakeholders.
- Conduct comprehensive medical claims reviews using benefit plans, policies, clinical guidelines, claims processing systems, member enrollment information, provider contracts, communication records, and applicable authorization/precertification systems.
- Analyze claims requiring clinical review and determine appropriate resolution in accordance with departmental policies and applicable state and federal requirements.
- Coordinate claim reviews and resolutions with internal departments, healthcare providers, health plans, business partners, and government agencies as needed.
- Maintain effective and professional written and verbal communication with internal and external stakeholders.
- Maintain current knowledge of medical policies, benefit plans, utilization criteria, department procedures, and requirements affecting medical claims review.
- Analyze claims data and monitor trends that may indicate opportunities for provider education, policy updates, departmental referrals, or further investigation.
- Prepare written recommendations based on review findings and follow through on identified opportunities for improvement.
- Collaborate with Special Investigations Unit (SIU) personnel on provider education, provider meetings, financial recoveries, and referrals to state or federal agencies.
- Track and report inventory, productivity, timeliness, and other performance statistics.
- Prepare ad hoc reports and identify opportunities for system, workflow, and process enhancements.
- Coordinate claims resolution with appropriate departments to ensure timely and accurate outcomes.
- Participate in task forces, special projects, continuing education, seminars, and webinars related to fraud, waste, abuse, medical management, and healthcare industry developments.
- Maintain a complete chain of custody for documentation and records, ensuring all stages of each review are properly documented.
- Testify or provide deposition testimony as an expert witness when required for legal proceedings.
- Create, update, and follow standard operating procedures, policies, confidentiality requirements, and information security guidelines.
- Assist with training new and existing staff as applicable.
- Perform additional duties and responsibilities as assigned.
- Intermediate proficiency with personal computers and office equipment.
- Intermediate proficiency with Microsoft Word and Excel.
- Experience navigating multiple software applications and maintaining electronic records.
- Knowledge of healthcare coding, medical terminology, billing processes, and health insurance reimbursement.
- Ability to learn and effectively use claims and healthcare-related systems.
- Strong clinical and healthcare knowledge.
- Ability to interpret and apply policies, procedures, contracts, benefit plans, programs, and clinical guidelines.
- Strong investigative, analytical, and research skills.
- Ability to gather, enter, maintain, and analyze information across multiple systems.
- Ability to understand, evaluate, and explain complex information clearly and concisely.
- Strong written and verbal communication skills.
- Excellent organizational and planning abilities.
- Strong critical-thinking and problem-solving skills.
- Ability to manage multiple priorities and meet deadlines in a fast-paced environment.
- Ability to work independently and exercise sound judgment.
- Ability to establish and maintain effective working relationships in a collaborative team environment.
- Ability to maintain confidentiality and protect sensitive information.
- Ability to follow established instructions, policies, and procedures.
- Advanced computer proficiency.
- Knowledge of laws and regulations related to healthcare insurance fraud and judicial processes associated with fraud investigations and prosecutions.
- Working knowledge of medical utilization review criteria, including InterQual or similar clinical criteria.
- Experience assisting with staff training and mentoring.
- Experience analyzing inventory and supporting special projects.
- Associate degree in a related field or post-secondary nursing diploma/certification from an approved program.
- Equivalent combination of education and relevant experience may be considered.
- Approximately 1–2 years of related medical coding, auditing, or clinical experience.
- No prior fraud, waste, and abuse experience required for entry-level positions.
- Knowledge of ICD-10 and CPT/HCPCS coding guidelines and terminology.
- CPC, CCS, or CPMA certification required within the specified introductory period, if applicable.
- Active, current, unrestricted Arizona professional healthcare license may be required for higher-level positions, including RN or LPN licensure.
- Approximately 2 years of medical coding or auditing experience.
- Approximately 2 years of experience in utilization review, quality assurance, or the health insurance industry.
- Bachelor's degree in Nursing or a related field.
- CPC — Certified Professional Coder.
- CCS — Certified Coding Specialist.
This position operates in a fast-paced environment requiring accuracy, confidentiality, strong analytical judgment, and the ability to manage multiple priorities. The role may be performed remotely and requires effective communication and collaboration across multiple departments and external stakeholders.
Medical Claims Review • Fraud, Waste & Abuse • Healthcare Insurance • Medical Coding • Clinical Review • Utilization Review • Claims Analysis • Healthcare Reimbursement • Investigations • Compliance • Data Analysis • Provider Relations • Quality Assurance • Financial Recovery • Regulatory Requirements • Documentation & Records Management #IND1
