Clinical Review Mana....
Clinical Review Manager
Posted on :
03-05-2024
Employer Active
1 Vacancy
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Job Description
Req ID : 2786476
This is a remote position.
We are currently seeking a highly skilled and experienced individual to join our team as a Clinical Review Manager. In this role you will provide leadership and oversight to the Review and Evaluation Process ensuring efficient and effective utilization of resources while maintaining high standards of care.
Key Responsibilities:
Provide managerial leadership and oversight to the Review and Evaluation Process.
Capably perform all tasks of the Review and Evaluation nurse as needed.
Evaluate and implement system and process improvements to enhance efficiency and effectiveness.
Assist in the development of inhouse training programs including initiatives for the Quality Improvement Program.
Become proficient in understanding and serving as a resource for claims processing through the PROMISe system.
Assist with coding and procedure coding groupings to ensure accuracy and compliance.
Interface with providers to address billing/claims issues and facilitate resolution.
Participate in the Quality Improvement Program to continuously improve processes and performance.
Requirements
Active Pennsylvania Nursing License.
Documented five years or more of experience in utilization review.
Knowledge of ICD9 CM coding.
Functional knowledge of Microsoft Office.
Proficient writing and verbal communication skills.
Strong understanding of utilization review processes.
Ability to apply regulations policies and standards effectively.
Ability to establish and maintain effective working relationships.
Ability to review and evaluate provider documentation to determine compliance with regulations.
Active Pennsylvania Nursing License. Case Management certification with either the National Academy of Certified Care Managers or American Nurses Credentialing Center. Minimum of two years experience in Care Management. Functional knowledge of Microsoft Office. Excellent writing and verbal communication skills. Strong understanding of Care Management processes.
Employment Type
Full Time
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