Medical Claims Review Manager jobs in Sacramento, 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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Claims Clinical Review Nurse, Senior
  • Blue Shield of California
  • El Dorado Hills, CA FULL_TIME
  • Your Role

    The FEP Post Service (PS-CR) department is BSC Federal Employee Program (FEP) retrospective clinical review program that entails detailed claims review of billed physician services and related outpatient facility services against FEP medical benefit and/or payment policy. The Post Service Clinical Review nurse will report to the manager of FEP Post Services. In this role you will be  reviewing claims and medical records review of services rendered to FEP members. Post-Service Clinical Nurse reviews for medical necessity, medical policy, benefits, and clinical coding. Post-Service Clinical Review is accountable for the initial review process through the final appeal as dictated by FEP policy. Post-Service Clinical Review works in coordination with other claims and appeals departments to ensure providers are paid appropriately and members receive quality care.

    Your Work

    In this role, you will:

    • Perform clinical claim reviews and first claim level determination approvals for members using FEP evidenced based guidelines, policies and nationally recognized clinal criteria
    • Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance  
    • Prepare and present cases to Medical Director (MD) for medical director oversight and medical necessity determination and communicate determinations to providers and/or members in compliance with federal and accreditation requirements 
    • Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards 
    • Triages and prioritizes cases to meet required turn-around times 
    • Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate 
    • Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary 
    • Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives 
    • Other duties as assigned

    Your Knowledge and Experience

    • Requires a current California RN License 
    • Requires 5 years of relevant experience
    • Typically, requires a college degree or equivalent experience and prior relevant experience In Post Service/Claims Review, Prior Auth Experience or Outpatient Claims Experience
    • Knowledge of CPT, ICD-10, HCPCs and provider billing practices 
    • Demonstrate the ability to act independently using sound clinical judgement
    • Experience in a fast paced, production and quality environment preferred 
    • Demonstrated efficient, time management techniques and skills 
    • Able to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business based turnaround times

    Pay Range:

    The pay range for this role is: $ 87230.00 to $ 130900.00 for California.

    Note:

    Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.


    About the Company:
    Blue Shield of California



  • 1 Month Ago

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Finance and Accounting Manager (Agile/Hybrid)
  • Sedgwick Claims Management Services Inc.
  • Sacramento, CA 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...
  • 5 Days Ago

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Claims Manager
  • Lucent Health Solutions LLC
  • Rancho Cordova, CA FULL_TIME
  • Title: Manager of ClaimsSummary: The Manager of Claims position is a key part of the department’s successful operation. This position has direct responsibility for all Commercial and Native American C...
  • 19 Days Ago

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Claims Manager
  • Dwayne Nash Industries, Inc
  • Roseville, CA FULL_TIME
  • Join Our Safety Team as a Claims Manager! Are you ready to embark on a career journey that goes beyond the ordinary? We're searching for individuals who embody the essence of engagement, accountabilit...
  • 1 Month Ago

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NorCal AOE/COE Claims Investigator
  • Atlas Claims Investigation
  • Sacramento, CA PART_TIME
  • Atlas Claims Investigation is looking for an experienced Workers' Compensation Investigator to conduct AOE/COE investigations in the Northern California region on a part time basis.Part Time W2 or 109...
  • 4 Days Ago

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CA - Nor Cal - 1099 Claims Adjuster
  • Copper Claims Services, Inc.
  • Sacramento, CA 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...
  • 4 Days Ago

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

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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

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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

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Remote Licensed Mental Health Counselor
  • Headway
  • Sacramento, CA
  • Remote Licensed Mental Health Counselor (LMHC) Wage: Between $120-$131 an hour Are you a Licensed Mental Health Counselo...
  • 3/28/2024 12:00:00 AM

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Remote Licensed Clinical Psychologist
  • Headway
  • Sacramento, 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 Clinical Social Worker
  • Headway
  • Sacramento, CA
  • Remote Licensed Clinical Social Worker (LCSW) Wage: Between $120-$131 an hour Are you a Licensed Clinical Social Worker ...
  • 3/26/2024 12:00:00 AM

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Remote Licensed Professional Counselor
  • Headway
  • Sacramento, 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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Supported Living Caregiver - Immediate positions available!
  • GOOD LIFE SLS LLC
  • Sacramento, CA
  • Job Description Job Description NO EXPERIENCE NECESSARY! Job Description: Staff for adults with developmental and physic...
  • 3/26/2024 12:00:00 AM

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Remote Licensed Mental Health Therapist
  • Headway
  • Sacramento, CA
  • Remote Licensed Mental Health Therapist (LMHT) Wage: Between $120-$131 an hour Are you a Licensed Mental Health Therapis...
  • 3/26/2024 12:00:00 AM

Sacramento (/ˌsækrəˈmɛntoʊ/ SAK-rə-MEN-toh; Spanish: [sakɾaˈmento]) is the capital city of the U.S. state of California and the seat of Sacramento County. Located at the confluence of the Sacramento River and the American River in Northern California's Sacramento Valley, Sacramento's estimated 2018 population of 501,334 makes it the sixth-largest city in California and the ninth largest capital in the United States. Sacramento is the seat of the California Assembly, the Governor of California, and Supreme Court of California, making it the state's political center and a hub for lobbying and th...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$105,423 to $134,416
Sacramento, California area prices
were up 2.5% 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