Medical Claims Review Manager oversees the performance, productivity, and quality of the medical claims review staff. Responsible for hiring, training, and firing medical claims review staff. Being a Medical Claims Review Manager evaluates medical claims review processes and recommends process improvements. Serves as a technical resource for all medical review workers. Additionally, Medical Claims Review Manager typically requires an RN or BSN. Requires a bachelor's degree. Typically reports to a head of a unit/department. The Medical Claims Review Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. Extensive knowledge of department processes. To be a Medical Claims Review Manager typically requires 5 years experience in the related area as an individual contributor. 1 to 3 years supervisory experience may be required. (Copyright 2024 Salary.com)
All the benefits and perks you need for you and your family:
Benefits from Day One
Our promise to you:
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Schedule: Full time
Shift: Day
Location: 7700 South Broadway, Littleton, CO 80122
The community you’ll be caring for: AdventHealth Littleton
The role you’ll contribute:
The purpose of the Peer Review Program Manager position is to ensure quality patient care by effectively managing the Medical Staff’s Peer Review Program, which encompasses the ongoing and focused professional performance review processes, the clinical care case referral/disposition processes, and the professional conduct case referral/disposition processes. Due to multiple Medical Staffs and facilities, this Program Manager must establish many effective relationships, work within multiple organizational structures and cultures, manage various systems/policies, and move between facilities with ease. They manage multiple Medical Staffs in the functioning for analyzing practitioner-specific patient care data (case referrals, medication safety, mortality review, length of stays, occurrences, complaints, etc.). Ensures the Medical Staff’s education and knowledge in methodologies of data management and interpretation, for the purpose of improving patient care.
This position administers a regulatory-compliant, effective and efficient peer review program, from data gathering through facilitating the Medical Staff’s governance systems in the area of peer review. These functions involve support to and communications with numerous hospital departments, executive administration, and the governing board, pursuant to the requirements set forth in Medical Staff Bylaws and Federal/State laws. The Peer Review Program Manager must direct, educate and motivate physician leaders to accomplish their assigned tasks either with matters of significance to department business or in support of the credentialing program. The position is also responsible for the integration of services between the MSSD, IT and Quality Departments with regards to the peer review program.
The value you’ll bring to the team:
The expertise and experiences you’ll need to succeed:
Minimum qualifications:
High School diploma or GED or 1 year work experience
Associate’s degree or Bachelor's degree in healthcare related field strongly preferred; in lieu of degree, 2 years of experience in healthcare related field
Preferred qualifications: