Medical Claims Review Manager jobs in Colorado

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
  • Denver, CO 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.

  • 2 Months Ago

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Field Case Manager
  • Sedgwick Claims Management Services Inc.
  • Denver, CO OTHER
  • 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...
  • 10 Days Ago

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Physician Telecommute Medical Review Stream
  • Concentra
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified physician? Candidates must have a CO license and currently have or interested in obtaining Level 1 or Level 2 Accreditation. Are you passionate about y...
  • 3 Days Ago

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Neurosurgeon Telecommute Medical Review Stream
  • Concentra
  • Colorado, CO OTHER
  • Overview Are you an accomplished Board Certified Neurosurgeon? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Are you passionate about your work/life balance? We are seeking...
  • 3 Days Ago

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Neurosurgeon Telecommute Medical Review Stream
  • Concentra Career Choice
  • Colorado, CO OTHER
  • Overview Are you an accomplished Board Certified Neurosurgeon? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Are you passionate about your work/life balance? We are seeking...
  • 4 Days Ago

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Physician Telecommute Medical Review Stream
  • Concentra Career Choice
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified physician? Candidates must have a CO license and currently have or interested in obtaining Level 1 or Level 2 Accreditation. Are you passionate about y...
  • Just Posted

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Hospital Medical Leader
  • Petco
  • Folsom, CA
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 6/10/2024 12:00:00 AM

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Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Alameda, CA
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 6/9/2024 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...
  • 6/9/2024 12:00:00 AM

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Head of Medical Writing
  • Barrington James
  • Clinical-stage biopharmaceutical company in San Francisco, is seeking a Head of Medical Writing. This leadership role in...
  • 6/8/2024 12:00:00 AM

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Head of Medical Strategy
  • ExecuSearch
  • Atlanta, GA
  • The Head of Medical Strategy provides medical expertise to the rheumatology commercial and medical teams and provides cl...
  • 6/8/2024 12:00:00 AM

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Head of Medical Strategy Rheumatology
  • UCB
  • Atlanta, GA
  • Make your mark for patients The Head of Medical Strategy provides medical expertise to the rheumatology commercial and m...
  • 6/8/2024 12:00:00 AM

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Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Pinellas Park, FL
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 6/8/2024 12:00:00 AM

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Head of Medical Writing
  • Barrington James
  • San Francisco, CA
  • Head of Medical Writing - Rare disease Biotech We are currently partnered with a growing, west coast based biotech focus...
  • 6/7/2024 12:00:00 AM

Colorado (/ˌkɒləˈrædoʊ, -ˈrɑːdoʊ/ (listen), other variants) is a state of the Western United States encompassing most of the southern Rocky Mountains as well as the northeastern portion of the Colorado Plateau and the western edge of the Great Plains. It is the 8th most extensive and 21st most populous U.S. state. The estimated population of Colorado was 5,695,564 on July 1, 2018, an increase of 13.25% since the 2010 United States Census. The state was named for the Colorado River, which early Spanish explorers named the Río Colorado for the ruddy silt the river carried from the mountains. The...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$99,984 to $127,482

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