Medical Claims Review Manager jobs in Boca Raton, FL

Summary

The responsibilities of the individual in this position include but are not limited to the following: a) Follow up on patient accounts when authorization for stay is required, fax numbers to send clinical reviews; b) Follow up on each account during the stay and on discharge for authorization - document in the electronic system; c) Escalate any potential disputes or denial of accounts to Director of Case Management or designee; d) Trends disputed claims by payor and physician; e) assist in obtaining authorization for patient discharged to Skilled Facilities or other post-acute care who require authorization and f) other duties as assigned. Also provides general support for Case Managers with insurance cases, denials, appeals, etc. Provides assistance to Case Management staff, Insurance companies and Home Health Agency representatives in a positive and professional manner. Maintains and demonstrates excellent organizational and communication skills in dealing with physicians, patients, public and members of the hospital staff when an assertive but tactful demeanor is required. Maintains confidential files of correspondence, statistical reports and documents relative to operation and prepares confidential correspondence for the Case Management Team with little or no direction. Coordinates, assists and advises on a variety of meetings, seminars, services and/or programs.

Qualifications

Education

Required: High school graduate or equivalent
Preferred: Associates or bachelor's degree; Nursing background

Experience

Proficiency in MS Word, Excel and PowerPoint presentation applications; Internet; Medical Terminology and/or Healthcare experience required. Previous experience coordinating operations and management activities required. Acute hospital experience preferred

Required

Certification/Licensure/Registration

None required;

Paramedic, EMT or Nursing Assistant certification preferred

Other Qualifications

Demonstrated good problem solving abilities and organizational skills. Demonstrated ability to provide service excellence in daily activities. Solid verbal and written communication skills

#LI-RS1

Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.