Medical Claims Review Manager jobs in Carson City, NV

Description

US:NV:Carson City Integrated Care Management

Per Diem Day Shift

About Carson Tahoe Health

CTH is a not-for-profit healthcare system with 240 licensed acute care beds, fully accredited by the Center for Improvement in Healthcare Quality (CIHQ). CTH was voted 5^th most beautiful hospital in the nation nestled among the foothills of the Sierra Nevada in North Carson City and only a short drive away from world-famous Lake Tahoe & Reno. We serve a population of over 250,000 and feature two hospitals, two urgent cares, an emergent care center, outpatient services and a provider network with 19 regional locations.

Summary

This position is responsible for facilitating care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources while respecting patient’s right to self-determination. This position has the overall responsibility to maintain current knowledge of disease processes, available resources, treatment options appropriate to patient population and reviewing medical necessity, responding to authorization concerns, and/or reconciling coverage related issues. This position collaborates with medical staff, interdisciplinary team, and external resources to screen for accurate medical necessity and appeal appropriate accounts according to internal guidelines.

Responsibilities

• Transition management – Assigns appropriate length of stay, participates in readmission prevention, transition level of care and patient satisfaction • Utilization management – Screens for accurate medical necessity using approved evidenced based criteria, application of supporting medical necessity and denial prevention utilizing physician advisor when necessary • Reviews clinical denials and initiates process, if determined appeal appropriate according to internal guidelines • Clinical Appeals - Responsible for drafting, finalizing, and sending clinical appeal letters in order to reverse a denial for payment on an insurance claim • Uses provided tools and patient medical records, working within and through the regulations to develop a documented response to the denial and overturn the payer's decision • Stays current with assigned accounts and follow-up on the appeal after submission to determine next steps to ensure appeals are overturned or upheld • Responsible for appealing denials using clinical based rationale, the need to produce high quality work with meeting compliance timeframes and production goals • Supports billing and authorization coordination staff in reviewing high-risk and high-dollar accounts before claim submission to prevent clinical denial • Works in partnership with Integrated Care Management Authorization Coordinators and Admin Staff • Assists staff in care coordination and demonstrating efficient throughput while assuring care is sequenced and at appropriate level of care • Accurately conducts a thorough, objective assessment of patient’s current status, including psychosocial, physical, financial, educational needs, treatment course and services needed • Compliance with state and federal regulations, The Joint Commission’s standards, Center for Improvement in Healthcare Quality (CIHQ), Conditions of Participation and hospital policy • Maintains current knowledge of disease processes, available resources, and treatment options appropriate to patient population • Collaborates with interdisciplinary team to promote patient throughput and efficient use of resources • Continuously demonstrates a positive attitude and understanding of case management philosophy, supports team building, and is motivated to fulfill department objectives • Utilizes Evidence -based clinical guideline tool (Milliman Care Guidelines ® or InterQual ®) • Documents all activity according to policy, including the electronic automated systems • Precepts new staff members and is a resource to all staff • Participates in department quality improvement initiatives and projects as assigned • Ability to perform role remotely and maintain collaboration with interdisciplinary team • Performs other related duties as assigned

Qualifications

• Required o Minimum (2) years of acute care hospital patient care experience o Current unrestricted registered nurse license in the State of Nevada o Organizational skills, excellent verbal & written communication skills, ability to lead, coordinate diverse group in fast paced environment, critical thinking, problem solving and negotiation skills • Preferred o Two (2) years of experience as acute care case manager o Bachelor of Science in Nursing o Ability to obtain Accredited Case Manager (ACM) certification

Top 5 Reasons to Live in Carson City, Nevada

• Live, work and play in one of the most beautiful regions in the world
• Enjoy an array of outdoor activities world class skiing, golf, camping, mountain biking, hiking, water skiing, kayaking, hunting and fishing
• Just next door is Beautiful Lake Tahoe
• We are minutes from Reno known as the 'biggest little city in the world' - Fine dining, nightlife, shopping and home to the University of Nevada Reno.
• Family friendly atmosphere with affordable housing & excellent school system

Our Benefits

• No State Income Tax
• Medical, Dental, Vision, FSA, Telehealth
• Paid Time Off, Mental Health, and Volunteer Days
• 100% Vested 401K & Roth with Company Contribution
• Tuition Reimbursement
• Referral Bonuses
• On Site Education & Certification Programs
• Base Wage Increases for Relevant Advanced Degrees
• Free Calm App Subscription