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)
POSITION SUMMARY
The Utilization Review Nurse is responsible for ensuring the medical necessity and appropriate level of care of all hospital admissions and extended hospital stays, including psychiatry; affirming compliance with CMS' Conditions of Participation regarding Utilization Management with annual review of the UM Plan and assisting with the coordination of the Utilization Management Committee; Knowledge of CMS policy, guidance and criteria as well as those of various managed care insurance plans.
MINIMUM REQUIREMENTS
State of Vermont Registered Nurse (RN) license required. The University of Vermont Health Network is moving toward an all Bachelor of Science in Nursing (BSN) workforce.
PRIOR EXPERIENCE
3-5 years acute care hospital nurse and/or
3-5 years chart review, prior authorizations, managed care, familiarity of clinical documentation requirements