Medical Claims Review Manager jobs in Colorado

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)

A
Peer Review Program Manager
  • AdventHealth Rocky Mountain
  • Littleton, CO FULL_TIME
  • Description


    All the benefits and perks you need for you and your family:

    Benefits from Day One

    • Paid Days Off from Day One
    • Student Loan Repayment Program
    • Career Development
    • Whole Person Wellbeing Resources
    • Mental Health Resources and Support

    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:

    • Administers a regulatory-compliant, effective peer review program, from data maintenance/mining in the EMR through facilitation the entire due process
    • Aggregates, analyzes, presents and maintain practitioner specific quality data.
    • Communicates with each practitioner to ensure records are identify and analyzed for the evaluation of competence.
    • Researches and prepares case synopsis for assignment to Committee for initial evaluation of referred cases.
    • Coordinates agendas and facilitates Peer Review Committee meetings; creates all documentation/materials and communicates directly with involved practitioners.
    • Develops, implements and improves the processes and procedures for the Focused and Ongoing Professional Practice Evaluations of the medical staffs and advanced practice providers.
    • Creates standard processes and procedures to track timely completion of peer and medical staff quality reviews.
    • Maintains FPPE and OPPE reports and processes.
    • Responsible for the integration of services between the Medical Staff, IT and Quality departments with regards to the peer review program, including peer and medical staff quality review findings into the credentialing reappointment process in conjunction with TJC standards.
    • Represents the Medical Staff in regulatory readiness plans/committees for TJC, CMS and DOH.
    • Researches and develops relevant and appropriate educational activities based upon the outcomes of peer review findings.
    • Identifies and accumulates data for analyses for practitioner specific review, procedural trends and rule rate indicates.
    • Obtains clinical evidence from appropriate literature or standards and comparison information from relevant databases.
    • Evaluates, verifies and challenges when appropriate, the aggregated data to ensure the integrity of the program.
    • Identifies and reports our negative trends or individual incidents to mitigate the organization’s risk.
    • Collaborates with Medical Staff leaders to determine action plans, implements and documents action plans and ensure follow- up.
    • Maintains current knowledge of the Medical Staff Bylaws, Rules and Regulations, and Peer Review Policies, as well as Peer Review/OPPE/FPPE requirements from TJC to meet all standards, serving as a technical resource to the Medical Staff.
    • Promote a team environment, willing to assist others, and responds timely to physicians, hospital staff and various external entities.
    • Responsible for protection of highly confidential and sensitive information, including peer review and HIPAA protected information.
    • Establish productive relationships with various stakeholders to ensure compliance and effective systems.

    Qualifications


    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:

    LPN/RN training preferred, but not required in lieu of strong knowledge of clinical/medical terminology and ability to navigate EMRs to discern critical information and acquire key data.



    This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances.
  • 18 Days Ago

S
Utilization Review Manager
  • Springstone, Inc.
  • Englewood, CO FULL_TIME
  • Overview Fully On-Site Role Utilization Review Manager Salary/Hourly: $65-75,000/yr Denver Springs Summary of Benefits Link Members of our team Enjoy: Working with a highly engaged staff Healthy staff...
  • 1 Month Ago

D
Utilization Review Manager
  • Denver Springs
  • Englewood, CO FULL_TIME
  • Overview Fully On-Site Role Utilization Review Manager Salary/Hourly: $65-75,000/yr Denver Springs Summary of Benefits Link Members of our team Enjoy: Working with a highly engaged staff Healthy staff...
  • 1 Month Ago

C
Physician Telecommute Medical Review Stream
  • Concentra Career Choice
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified physician in one of the below specialties? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Emergency Medicine Internal Medici...
  • Just Posted

C
Physician Telecommute Medical Review Stream
  • Concentra
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified physician in one of the below specialties? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Emergency Medicine Internal Medici...
  • Just Posted

C
CO - 1099 Property Claims Adjuster
  • Copper Claims Services, Inc.
  • Denver, CO FULL_TIME
  • 1099 Property Claims Adjuster Copper Claims Services is a quickly growing independent loss adjusting firm based out of Irvine, CA. Copper Claims Services excels in providing custom claims solutions fo...
  • 7 Days Ago

P
Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Folsom, CA
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 3/28/2024 12:00:00 AM

P
Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Saratoga Springs, NY
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 3/28/2024 12:00:00 AM

P
Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Orem, UT
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 3/28/2024 12:00:00 AM

P
Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Fairfield, CA
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 3/28/2024 12:00:00 AM

S
Medical Lead - Oncology, Medical Affairs
  • SEC Life Sciences
  • One of the world's leading pharmaceutical companies is seeking four passionate, forward-thinking individuals for key rol...
  • 3/28/2024 12:00:00 AM

P
Hospital Medical Leader
  • Petco
  • Menifee, CA
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 3/27/2024 12:00:00 AM

R
Executive Director, Head of Medical Affairs, Immunology
  • RBW Consulting
  • Philadelphia, PA
  • A major international pharma business is looking to expands its immunology pipeline and requires a dynamic and forward t...
  • 3/25/2024 12:00:00 AM

M
Head of Medical Writing
  • Morgan Prestwich - Life Science & Healthcare Executive Search
  • Company Overview Morgan Prestwich is thrilled to be representing our client on an exclusive basis. Our client is a clini...
  • 3/24/2024 12:00:00 AM

Colorado (/ˌkɒləˈrædoʊ, -ˈrɑːdoʊ/ (listen), other variants) is a state of the Western United States encompassing most of the southern Rocky Mountains as well as the northeastern portion of the Colorado Plateau and the western edge of the Great Plains. It is the 8th most extensive and 21st most populous U.S. state. The estimated population of Colorado was 5,695,564 on July 1, 2018, an increase of 13.25% since the 2010 United States Census. The state was named for the Colorado River, which early Spanish explorers named the Río Colorado for the ruddy silt the river carried from the mountains. The...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$98,355 to $125,404

Medical Claims Review Manager in Parkersburg, WV
This end-to-end e-billing and e-payment solution is fully integrated with DecisionPoint, which means it can be immediately and easily integrated with your providers, adjusters, IT infrastructure, and claims workflow—enabling you to.
January 01, 2020
Medical Claims Review Manager in Juneau, AK
Examples include a claims examiner’s view of a particular bill’s status in a claim record’s related bill screen, or a bill review analyst’s view of an available reserve amount for the claim record related to the bill they are processing.
December 03, 2019
Medical Claims Review Manager in Galveston, TX
Assists the Manager, Medical Review with performing duties to oversee day-to-day activities within the Medical Claims Review Department to facilitate the achievement of business goals and targets.
December 16, 2019