Medical Claims Review Manager jobs in California

Core Competencies

• Adheres to policies, procedures, and standards of practice to deliver safe and optimal care
  
  
• Complies with Joint Commission’s national patient safety goals
  
  
• Complies with organizational quality dashboard/benchmarking goals
  
  
• Maintains regulatory compliance consistent with quality standards and ethical obligations of the profession
  
  
• Participates in organizational committees, task forces and/or projects including presentation of project reports, committee recommendations, and task force activities at the unit level
  
  
• Participates in Peer Review
  
  
• Participates in professional development activities
• Provides age specific and culturally competent discharge planning to all patients.

Department Specific Competencies

• Ensures medical necessity of cases by performing daily continued stay reviews on commercial patients as per contract or payer expectation.
  
  
• Collaborate with revenue cycle team (Physician Advisor, Case Management, Insurance Verification, etc..) to mitigate potential denials.
  
  
• Accepts referrals from hospitals, physician offices, SNF's and other community referral sources, obtains required orders for services and coordinates infusion products and DME/HME delivery.
  
  
• Accesses computer system(s) for retrieval of patient information
  
  
• Acts as a liaison between Healthcare Partners and department on contracting, billing, authorization, claims payment and other issues.
  
  
• Demonstrates independent judgment, autonomy, initiative, time management and organizational skills and the ability to prioritize projects/functions in a busy work environment.
  
  
• Acts as a resource for TMIPA, TMPN and TMIP

Education

Experience

License / Certification Requirements

Compensation Range 

$53.40 - $82.22 / Hour