Medical Claims Review Manager jobs in Fairfield, CA

100% Remote, Work-From-Home position anywhere in the US. (Any state RN license is accepted).

As an RN, you will provide direction, guidance, and support to our physician Medical Claims Reviewers as well as other staff as indicated. Complete quality audits of individual case reviews.

Support the clinical aspects of the review process and case reviews, including but not limited to:

• Support the reviewer selection and assignment process
• Resolve operational issues arising in connection with the clinical aspects of review cases
• Communicate with assigned reviewers and with treating/ordering practitioners/providers
• Support the Case Fulfillment process and provide education to analysts as appropriate
• Advise and provide guidance to reviewers on the operational aspects of review cases in all categories (i.e., standard, and ERO cases) and provide them with information pertinent to their assigned cases and related review processes
• Collaborate with the Chief Medical Director and Director of Provider Relations to address reviewer quality issues; support the Provider Relations assessment process

Qualifications:

• 2 Year Degree
• Qualified candidates will be self-directed, assertive, and creative in problem-solving, as well as a keen eye for detail
• Very strong computer literacy and high competency in the use of Microsoft Office are a must
• Strong analytical skills
• Strong oral and written communication skills
• Ability to work under pressure and meet deadlines while managing multiple high priorities and maintain a flexible schedule

• 
  Schedule: 5, 8-hour shifts each week - which includes a Saturday and Sunday rotation
• Scheduled 8 hours per day, between the hours 7am to7:00pm Mountain Time