RN Navigator Case Manager performing case management in Miami, Florida with emphasis on improving care coordination. Engaging members and providers for optimal health outcomes while ensuring adherence to medical necessity guidelines.
BC
Hybrid Manager, Medical Review – Medicare Appeals, Utilization Review, Part A, HHH
Posted 19 minutes ago
About the role
- Manager overseeing medical claim reviews ensuring compliance with standards and implementing process improvements. Engaging with regulatory bodies and maintaining quality performance standards in healthcare.
Responsibilities
- Manages the medical review process
- Maintains a well-trained staff
- Develops/implements medical review strategy with the ultimate goal of reducing the error rate
- Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations
- Identifies missed standards and implements corrective actions
- Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action
- Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner
- Interfaces with internal and external customers such as appellants/attorneys, congressional offices , and other regulatory bodies as required to build and maintain positive customer relationships
Requirements
- Bachelor's degree in a job-related field
- 5 years clinical and utilization review to include 2 years supervisory or team lead experience or equivalent military experience in grade E4 or above
- Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills
- Good judgment skills
- Proficient spelling, grammar, punctuation, and basic business math
- Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion
- Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes
- Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)
Benefits
- Subsidized health plans
- Dental and vision coverage
- 401k retirement savings plan with company match
- Life Insurance
- Paid Time Off (PTO)
- On-site cafeterias and fitness centers in major locations
- Education Assistance
- Service Recognition
- National discounts to movies, theaters, zoos, theme parks and more
Job title
Job type
Experience level
Salary
Not specified
Degree requirement
Location requirements
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