Manager, Medical Claims Review
Our Mission: Provide the best value in health insurance and related health services to improve the quality of life for Arizonans.
Inspire health in Arizona as the trusted leader in delivering affordable, innovative healthcare solutions.
Our Benefits: Our benefits provide work-life balance and the flexibility you need to be your best. We offer comprehensive medical, dental, and vision coverage; a 401K savings plan; paid holidays and vacations; and much more!
The Manager, Medical Claims Review department is responsible for leading a team of nurses and paraprofessionals in reviewing and analyzing medical claims to ensure medical necessity for services rendered, right level of care, correct billing and coding procedures are substantiated for inpatient and outpatient claims. This position requires consistent application of InterQual Criteria and Medicaid and Medicare billing and coding expertise.
- Develops procedures and processes for team adherence to claim review and documentation based on best practice
- Write job aids, policies, train staff, and ensure all regulatory standards are met for Medicaid, Medicare, and NCQA
- Evaluate data and provide direction, course correction, and leads process improvement
- Coach and mentor staff; work with senior leaders on employee performance issues
- Directs professionals and paraprofessionals to deliver on all KPIs for the health plan
- Tracks data, analyzes findings for medical claims decisions, disputes, and provider response
- Meets with providers in JOCs and as needed
- Responsible for the day to day operations of the department
- Conducts claim reviews and provides accurate and detailed abstracts for Medical Director review
- Maintains and updates authorizations in medical management system and the claims system
- Collaborates with Network Services leadership to educate providers on correct coding, billing, and clinical documentation
Education / Experience / Other Requirements
- RN; BSN preferred
- Arizona unrestricted RN license required
- Certified coder
Years of Experience:
- 2-3 years direct clinical experience
- 1-2 years managed care/health plan experience preferred
- 1-2 years medical claims review experience
- Medicaid and Medicare experience preferred
- Prior management experience 2 or more years
- Claims review tenets
- Computer skills including MS Word, Excel spreadsheets
- Communication skills: oral and written
Skills & Abilities:
- Ability to manage multiple projects and prioritize adhere to deadlines/time frames
- Ability to supervise and lead others
- Ability to manage regulatory deliverables