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)
Under general supervision, the Utilization Review Case Manager (UR CM) performs review of patient referral and medical record for appropriateness for Skilled Home Health services. The UR CM validates the patient’s admission and appropriate visits based on the skilled needs of the patient. The UR CM uses medical necessity based on the Skilled Clinician Start of Care assessment and ongoing needs. The UR CM secures authorization for the patient’s clinical services through collaboration and communication with payers as required. The UR CM provides oversight for the patients continued skilled needs, number of visits and secures authorization from the health plan. The UR CM is a liaison between home health and the health plan. |
Core Competencies |
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Department Specific Competencies |
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Education | |
Degree | Program |
Associates | Nursing |
Experience | |
Number of Years Experience | Type of Experience |
1 | Home Health Experience |
Experience with OASIS case management in Home Health
License / Certification Requirements |
Registered Nurse License |
Compensation Range $53.40 - $82.22 / Hour |
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0 Medical Claims Review Manager jobs found in Torrance, CA area