Medical Claims Review Manager jobs in Ohio

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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RN Medical Claims Review Nurse (Remote)
  • Morgan Stephens
  • Columbus, OH FULL_TIME
  • Medical Claims Review Nurse
    Position is fully remote
    Schedule: M-F 9AM-5PM local time. The training schedule will be M-F 9AM-5PM EST.
    Daily responsibilities: Candidates will be reviewing medical patient records against standard medical criteria.
    Candidates MUST have 3 years of clinical appeals experience along with 1 year of utilization review experience. Candidates with DRG experience on the resume will be prioritized for interviews.

    JOB SUMMARY:
    • Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
    • Identifies and reports quality of care issues.
    • Identifies and refers members with special needs to the appropriate healthcare organization program per
    policy/protocol.
    • Assists with Complex Claim review; requires decision making pertinent to clinical experience
    • Documents clinical review summaries, bill audit findings and audit details in the database
    • Provides supporting documentation for denial and modification of payment decisions
    • Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of healthcare organization policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
    • Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.
    • Supplies criteria supporting all recommendations for denial or modification of payment decisions.
    • Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and
    Member/Provider Inquiries/Appeals.
    • Provides training, leadership and mentoring for less experienced clinical peers and LVN, RN and
    administrative support staff.
    • Resolves escalated complaints regarding Utilization Management and Long Term Services & Supports
    issues.
    • Identifies and reports quality of care issues.
    • Prepares and presents cases in conjunction with the Chief Medical Officers Medical Directors for
    Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
    • Represents the healthcare organization and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.

    JOB FUNCTION:
    Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

    REQUIRED EDUCATION:
    Highschool Diploma or GED

    REQUIRED EXPERIENCE:
    Minimum three years clinical appeals review experience.
    Minimum one year Utilization Review

    REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
    Active, unrestricted State Registered Nursing (RN) license in good standing.

  • 1 Day Ago

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Molina Claims Review Specialist
  • Council on Aging of Southwestern Ohio
  • Blue, OH FULL_TIME
  • Claims Review Specialist Council on Aging of Southwestern Ohio (COA) is a nonprofit organization dedicated to enhancing quality of life for older adults, people with disabilities, their families and c...
  • 10 Days Ago

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Claims Review Specialist
  • Sheakley Group, Inc
  • UNKNOWN, OH FULL_TIME
  • Job Summary The Claim Review Specialist is responsible for entering and processing initial claims and completing preliminary calls to employer, provider, injured worker and Bureau of Workers Compensat...
  • 25 Days Ago

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IT Applications Manager
  • Sedgwick Claims Management Services Inc.
  • Telecommuter OH, OH FULL_TIME
  • Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flex...
  • 26 Days Ago

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Medical Records Review Coordinator
  • BizTek People, Inc. | APA International Placement Consultants
  • Maumee, OH FULL_TIME
  • Title: Medical Records Review CoordinatorDuration: 12 WeeksLocation: Maumee, OH JOB DESCRIPTIONPerforms audits of medical records from primary care and specialty provider offices to collect medical fa...
  • 12 Days Ago

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Utilization Review Nurse - Utilization Management
  • METROHEALTH MEDICAL CENTER
  • Cleveland, OH FULL_TIME
  • Location: METROHEALTH MEDICAL CENTER Biweekly Hours: 64.00 Shift: variable start time, day shift The MetroHealth System is redefining health care by going beyond medical treatment to improve the found...
  • 9 Days Ago

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Coordinator, Clinical Studies - Thoracic-Head & Neck Medical Oncology
  • University Of Texas M.d. Anderson
  • Houston, TX
  • Coordinator, Clinical Studies - Thoracic-Head & Neck Medical Oncology The University of Texas MD Anderson Cancer Center ...
  • 4/19/2024 12:00:00 AM

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Senior Research Nurse - Thoracic Head & Neck Medical Oncology
  • MD Anderson
  • Houston, TX
  • The University of Texas MD Anderson Cancer Center is ranked the nation's top hospital for cancer care by U.S. News & Wor...
  • 4/18/2024 12:00:00 AM

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Technologist-Medical Lead - MG Diagnostic Lab BMG
  • Baptist Memorial
  • Germantown, TN
  • Summary Perform all functions of the Medical Technologist and supervise the personnel and activities of various sections...
  • 4/18/2024 12:00:00 AM

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Medical Management Specialist I
  • Integrated Resources Inc
  • Chicago, IL
  • Job Title: Medical Management Specialist I Location: Chicago/ Cook County, IL (remote+ Fild visit) Job Duration: 6 month...
  • 4/18/2024 12:00:00 AM

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Head of Medical Writing
  • Proclinical Staffing
  • Head of Medical Writing - Permanent - Onsite Proclinical is seeking a Head of Medical Writing to join a cutting-edge bio...
  • 4/17/2024 12:00:00 AM

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Head of Medical Writing
  • Aerovate Therapeutics Inc.
  • Waltham, MA
  • Aerovate (AVTE) is a clinical stage biopharmaceutical company focused on developing drugs that meaningfully improve the ...
  • 4/16/2024 12:00:00 AM

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Head of Medical Writing
  • Aerovate Therapeutics, Inc.
  • Waltham, MA
  • Aerovate (AVTE) is a clinical stage biopharmaceutical company focused on developing drugs that meaningfully improve the ...
  • 4/15/2024 12:00:00 AM

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Senior Director, Global Pharmacovigilance & Risk Management Head of Medical Safety
  • Vir Biotechnology, Inc.
  • Vir Biotechnology, Inc. is an immunology company focused on combining cutting-edge technologies to treat and prevent inf...
  • 4/15/2024 12:00:00 AM

Ohio /oʊˈhaɪoʊ/ (listen) is a Midwestern state in the Great Lakes region of the United States. Of the fifty states, it is the 34th largest by area, the seventh most populous, and the tenth most densely populated. The state's capital and largest city is Columbus. The state takes its name from the Ohio River, whose name in turn originated from the Seneca word ohiːyo', meaning "good river", "great river" or "large creek". Partitioned from the Northwest Territory, Ohio was the 17th state admitted to the Union on March 1, 1803, and the first under the Northwest Ordinance. Ohio is historically know...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$95,425 to $121,669

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