Medical Claims Review Manager jobs in Irvine, CA

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)

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Medical Case Manager Concurrent Review
  • SUNSHINE ENTERPRISE USA LLC
  • Orange, CA FULL_TIME
  • Medical Case Manager (Concurrent Review)


    Company Overview: Sunshine Enterprise is an industry-leading Staffing and Recruitment Firm. Our clients are fortune 500 companies, high growth start-up companies, government, and private equity firms, and lead professional services firms. As a leading force in the business landscape, we take pride in bringing together great people and great organizations by fostering a work environment that values creativity, diversity, and growth. If you're ready to embark on a rewarding career journey with a company that prioritizes its employees, explore our current job opportunities below.

    Job Summary: The Medical Case Manager (LVN) will be responsible for reviewing and processing requests for authorization and notification of medical services from health professionals, clinical facilities and ancillary providers. The incumbent will be responsible for prior authorization and referral related processes, which includes online responsibilities as well as select off-line tasks. The incumbent will utilize medical criteria, policies and procedures to authorize referral requests from medical professionals, clinical facilities and ancillary providers. The incumbent will directly interact with provider callers and serve as a resource for their needs.

    Position Responsibilities

    • Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
    • Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
    • Reviews requests for medical appropriateness.
    • Verifies and processes specialty referrals, diagnostic testing, outpatient procedures, home health care services and durable medical equipment and supplies via telephone or fax by using established clinical protocols to determine medical necessity.
    • Screens requests for Medical Director review, gathers pertinent medical information before submission to the Medical Director, follows up with the requester by communicating the Medical Director’s decision and documents follow-up in the utilization management system.
    • Completes required documentation for data entry into the utilization management system at the time of the telephone call or fax to include any authorization updates.
    • Reviews International Classification of Diseases (ICD-10), Current Procedural Terminology (CPT-4) and Healthcare Common Procedure Coding System (HCPCS) codes for accuracy and existence of coverage specific to the line of business.
    • Contacts the health networks and/or Customer Service department regarding health network enrollments.
    • Identifies and reports any complaints to immediate supervisor by utilizing the call tracking system or through verbal communication if the issue is of an urgent nature.
    • Refers cases of possible over/under utilization to the Medical Director for proper reporting.
    • Meets productivity and quality of work standards on an ongoing basis.
    • Assists the manager with identifying areas of staff training needs and maintains current data resources.
    • Completes other projects and duties as assigned.

    Possesses the Ability To:

    • Have strong problem solving, organizational and time management skills along with the ability to work in a fast-paced environment.
    • Travel to locations with frequency, as the employer determines is necessary or desirable, to meet business needs.
    • Establish and maintain effective working relationships with CalOptima Health’s leadership and staff.
    • Communicate clearly and concisely, both orally and in writing.
    • Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.


    Requirements

    •  Experience & Education

      • High School diploma or equivalent required.
      • Current, unrestricted Licensed Vocational Nurse (LVN) license to practice in the State of California required.
      • 3 years of nursing experience, with 1 year as a Clinical Nurse Reviewer, required.
      • 1 year of utilization management/prior authorization review experience required.
      • An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.

      Preferred Qualifications

      • Managed care experience. 
      • Active Certified Case Manager (CCM) certification.

      Knowledge of:
      • Guidelines and regulations relevant to utilization management.
      • Medical Terminology.
      • Medi-Cal and Medicare benefits and regulations.
      • Current Procedural Terminology (CPT-4), International Classification of Diseases (ICD-10), and Healthcare Common Procedure Coding System (HCPCS) codes and continual updates to knowledge base regarding the codes.


    Benefits

    At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization, and we are happy to offer the following benefits:

    • Competitive pay & weekly paychecks
    • Health, dental, vision, and life insurance
    • 401(k) savings plan
    • Awards and recognition programs
    • Benefit eligibility is dependent on employment status.

    SUNSHINE ENTERPRISE USA LLC is an Equal Opportunity Employer and does not discriminate based on race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.


  • 13 Days Ago

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Medical Case Manager - Concurrent Review
  • Sunshine Enterprise USA LLC
  • Orange, CA FULL_TIME
  • Company Overview:Sunshine Enterprise is an industry-leading Staffing and Recruitment Firm. Our clients are fortune 500 companies, high growth start-up companies, government, and private equity firms, ...
  • 15 Days Ago

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Medical Case Manager (Concurrent Review)
  • Sunshine Enterprise USA LLC
  • Orange, CA FULL_TIME
  • Medical Case Manager (Concurrent Review)Company Overview:Sunshine Enterprise is an industry-leading Staffing and Recruitment Firm. Our clients are fortune 500 companies, high growth start-up companies...
  • 15 Days Ago

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Medical Case Manager (LVN) (Concurrent Review)
  • CalOptima
  • Orange, CA FULL_TIME
  • Medical Case Manager (LVN) (Concurrent Review) Job Description Department(s): Utilization Management (Concurrent Review) Reports to: Supervisor, Utilization Management (Concurrent Review) FLSA status:...
  • 9 Days Ago

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Prior-Authorization Utilization Review Nurse (LVN) (Medical Case Manager (LVN))
  • CalOptima
  • Orange, CA FULL_TIME
  • Prior-Authorization Utilization Review Nurse (LVN) (Medical Case Manager (LVN)) Job Description Why CalOptima? CalOptima is the single largest health plan in Orange County, serving 880,000 members, or...
  • 1 Day Ago

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Community Design & Review Manager
  • FirstService Residential
  • Irvine, CA FULL_TIME
  • Position: Community Design and Review Manager Reports to:Director. Community Design and Review Location: Irvine, CA The Community Design and Review Team Manager will serve as the point of contact assi...
  • 10 Days Ago

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0 Medical Claims Review Manager jobs found in Irvine, CA area

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PHYSICIAN ASSISTANT - UROLOGY HSC
  • Hoag Memorial Hospital Presbyterian
  • Irvine, CA
  • Salary Range: 1.00 - 3.00 /hour. Actual compensation may vary based on geographic location, work experience, skill level...
  • 3/28/2024 12:00:00 AM

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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

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LVN
  • Kisco Senior Living
  • Irvine, CA
  • Job Description: The Licensed Nurse provides exemplary nursing services to residents. This is a part-time position, Sund...
  • 3/27/2024 12:00:00 AM

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Psychiatric Nurse Practitioner - Costa Mesa, CA
  • LifeStance Health
  • Costa Mesa, CA
  • At LifeStance Health, we believe in a truly healthy society where mental and physical healthcare are unified to make liv...
  • 3/27/2024 12:00:00 AM

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Remote Licensed Clinical Psychologist
  • Headway
  • Irvine, CA
  • Remote Licensed Clinical Psychologist Wage: Between $166-$196 an hour Are you a Licensed Clinical Psychologist looking t...
  • 3/26/2024 12:00:00 AM

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Remote Licensed Professional Counselor
  • Headway
  • Irvine, CA
  • Remote Licensed Professional Counselor (LPC) Wage: Between $120-$131 an hour Are you a Licensed Professional Counselor l...
  • 3/26/2024 12:00:00 AM

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Front/Back Office Assistant
  • Candy Medical Management
  • Hermosa Beach, CA
  • Job Description Job Description Pier Medical Aesthetics/ Candy Medical Mgmt is hiring a part-time to grow to full-time f...
  • 3/25/2024 12:00:00 AM

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Medical Front Desk and Admissions
  • TTF
  • Newport Beach, CA
  • Job Description Job Description TTF is recruiting a Front Desk/Admissions Rep for a large healthcare organization in New...
  • 3/25/2024 12:00:00 AM

Irvine (/ˈɜːrvaɪn/) is a master-planned city in Orange County, California, United States in the Los Angeles metropolitan area. The Irvine Company started developing the area in the 1960s and the city was formally incorporated on December 28, 1971. The 66-square-mile (170 km2) city had a population of 212,375 as of the 2010 census; in 2018 the California Department of Finance estimated the city's population at 276,176. A number of corporations, particularly in the technology and semiconductor sectors, have their national or international headquarters in Irvine. Irvine is also home to several hi...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$108,548 to $138,400
Irvine, California area prices
were up 3.0% from a year ago

Medical Claims Review Manager in Paramus, NJ
Support management with leading Medical Review team to ensure all types of claims requiring medical reviews are completed in compliance with State, Federal, accreditation standards and other applicable regulations.
February 01, 2020
Medical Claims Review Manager in Nashua, NH
By truly combining claims and bill review, the two systems are kept in sync utilizing the scheduled jobs of the aforementioned standard model; however, for real-time data updates, claims examiners are granted access to the entire live bill review system.
January 13, 2020
Medical Claims Review Manager in Davenport, IA
Complex claim errors can only be caught by physician reviewers with the clinical experience to spot mistakes that automated systems can’t detect.
January 03, 2020