Medical Claims Review Manager jobs in Atlanta, GA

Overview

We are seeking passionate and skilled RN’s to serve as a Quality Review Manager, reviewing cases and ensuring all necessary information has been provided and is accurate before sending back to requestor.

This position is 100% remote. 

The Quality Review Manager is responsible to work autonomously to complete full audit, review and approval of the following, but not limited to: Life Care Plans, Medical Cost Projections, Medicare Set-Aside Allocations, Legal Nurse Reviews, Complex Nurse Reviews, Bill Reviews, initial and progress reports for medical or vocational case management files and other reports as needed within the scope of nursing practice and certifications.  The Quality Review is responsible to monitor the overall quality of all the work products and effectively communicate with the planner team to include development of alternative treatment plans or recommendations for moving the file toward maximum resolution at the highest level of quality and timeliness possible.

Responsibilities

ESSENTIAL JOB FUNCTIONS

• Collaborates with Planner team through education and recommendations on past/future treatment to optimize outcomes with client interfacing
• Work autonomously and collaborate with the Clinical Services Team and all company personnel as needed and communicate with the accounts and attorneys as needed.
• Maintain through audit a quality work product evidenced by acceptable quality scores and standards.
• Participate in company orientation, management meetings and/or conference calls as required.
• Ensure all federal Centers for Medicare and Medicaid Services (CMS) requirements and/or state mandates are adhered to at all times.
• Provide insight and direction to management on report quality and compliance with all company policies and procedures, client specifications, URAC and CMS guidelines.
• Promote effective and efficient utilization of company resources.
• Participate in various educational and or training activities as required.

ESSENTIAL MANAGERIAL RESPONSIBILITIES

• Carrying out all responsibilities in accordance with the company’s standards, policies, and all applicable employment laws.
• Managing and monitoring workflow and providing support, training, and techniques to assist staff in achieving department daily/weekly/monthly goals and standards.
• Encouraging positive morale, maintaining harmony among staff, and resolving grievances when necessary.
• Overseeing the completion and approval of employee timecards and coordinating overtime needs with management and staff as needed.
• Actively participating in the department’s staffing requirements including hiring, onboarding, and separating of employees.
• Creating and implementing plan to meet department’s goals and metrics based on workload and client needs.
• Communicating change effectively and supporting those affected by change.
• Managing insubordinate staff when warranted and initiating coaching or corrective actions as required and/or directed by upper management.
• Evaluating staff needs and performance, providing periodic feedback to staff and reporting any performance concerns and/or recommendations growth opportunities to management.
• Actively participating and successfully conducting annual performance evaluations.

Qualifications

Education and/or Experience  

Associates degree required. Bachelor’s degree in health-related field preferred. Three to five years Medicare Compliance preferred and a minimum of three years worker’s compensation experience.

Certificates, Licenses, Registrations  

Active unrestricted Registered Nursing license. Must have minimum active certification in Medicare Set-Asides; additional certification in Life Care Planning and/or Legal Nurse Consulting preferred.

QUALIFICATIONS 

• Must have knowledge of the disability and workers' compensation industry including rules and regulations and an understanding of clinical procedures and all processes involved in the delivery of quality health care to an injured worker.
• Must be able to adequately operate a general computer and telephone.
• Must have strong knowledge of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet.
• Must have knowledge of current laws and regulations that govern delivery of rehabilitation services.
• Must have knowledge of human behavior and performance.
• Ability to demonstrate strong customer service knowledge including needs assessment, meeting quality standards for services and evaluation of customer satisfaction.
• Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed.
• Must be able to work independently, prioritize work activities and use time efficiently.
• Ability to concentrate and multitask in a fast-paced work environment.
• Must demonstrate accuracy and thoroughness and look for ways to improve and promote quality and monitor own work to ensure quality is met. 
• Must be able to demonstrate and promote a positive team -oriented environment.
• Must be able to work well under pressure and/or stressful conditions and have the ability to manage change, delays, or unexpected events appropriately.

ExamWorks is a leading provider of innovative healthcare services including independent medical examinations, peer reviews, bill reviews, Medicare compliance, case management, record retrieval, document management and related services. Our clients include property and casualty insurance carriers, law firms, third-party claim administrators and government agencies that use independent services to confirm the veracity of claims by sick or injured individuals under automotive, disability, liability and workers' compensation insurance coverages.

ExamWorks, LLC is an Equal Opportunity Employer and affords equal opportunity to all qualified applicants for all positions without regard to protected veteran status, qualified individuals with disabilities and all individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age or any other status protected under local, state or federal laws.

Examworks offers a fast-paced team atmosphere with competitive benefits (medical, vision, dental), paid time off, and 401k.

Equal Opportunity Employer - Minorities/Females/Disabled/Veterans