Medical Claims Review Manager jobs in Columbus, OH

Medical Claims Review Manager oversees the performance, productivity, and quality of the medical claims review staff. Responsible for hiring, training, and firing medical claims review staff. Being a Medical Claims Review Manager evaluates medical claims review processes and recommends process improvements. Serves as a technical resource for all medical review workers. Additionally, Medical Claims Review Manager typically requires an RN or BSN. Requires a bachelor's degree. Typically reports to a head of a unit/department. The Medical Claims Review Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. Extensive knowledge of department processes. To be a Medical Claims Review Manager typically requires 5 years experience in the related area as an individual contributor. 1 to 3 years supervisory experience may be required. (Copyright 2024 Salary.com)

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RN Medical Claims Review Nurse (Remote)
  • Morgan Stephens
  • Columbus, OH FULL_TIME
  • Medical Claims Review Nurse
    Position is fully remote
    Schedule: M-F 9AM-5PM local time. The training schedule will be M-F 9AM-5PM EST.
    Daily responsibilities: Candidates will be reviewing medical patient records against standard medical criteria.
    Candidates MUST have 3 years of clinical appeals experience along with 1 year of utilization review experience. Candidates with DRG experience on the resume will be prioritized for interviews.

    JOB SUMMARY:
    • Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
    • Identifies and reports quality of care issues.
    • Identifies and refers members with special needs to the appropriate healthcare organization program per
    policy/protocol.
    • Assists with Complex Claim review; requires decision making pertinent to clinical experience
    • Documents clinical review summaries, bill audit findings and audit details in the database
    • Provides supporting documentation for denial and modification of payment decisions
    • Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of healthcare organization policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
    • Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.
    • Supplies criteria supporting all recommendations for denial or modification of payment decisions.
    • Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and
    Member/Provider Inquiries/Appeals.
    • Provides training, leadership and mentoring for less experienced clinical peers and LVN, RN and
    administrative support staff.
    • Resolves escalated complaints regarding Utilization Management and Long Term Services & Supports
    issues.
    • Identifies and reports quality of care issues.
    • Prepares and presents cases in conjunction with the Chief Medical Officers Medical Directors for
    Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
    • Represents the healthcare organization and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.

    JOB FUNCTION:
    Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

    REQUIRED EDUCATION:
    Highschool Diploma or GED

    REQUIRED EXPERIENCE:
    Minimum three years clinical appeals review experience.
    Minimum one year Utilization Review

    REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
    Active, unrestricted State Registered Nursing (RN) license in good standing.

  • 7 Days Ago

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Appeals Specialist - Medical Claims
  • Morgan Stephens
  • Columbus, OH FULL_TIME
  • Job Title: Appeals Specialist Pay: $20.00 per hour (Full-remote - Preference Eastern Time Zone) Typical Schedule/Shift: Monday - Friday, 7:30 AM - 4 PM or 8 AM - 4:30 PM Summary: As an Appeals Special...
  • 7 Days Ago

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Manager - Multi-Line Claims
  • The Wendy's Company
  • Dublin, OH FULL_TIME
  • Overview: When our square shaped burgers made their first sizzle on the scene more than 50 years ago, people knew our approach wasn’t like any other. Same goes for the way we support our employees. Ou...
  • 14 Days Ago

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Commercial Property Claims Manager
  • Universal Fire & Casualty Insurance Company
  • Dublin, OH FULL_TIME
  • Universal Fire & Casualty Insurance Company is seeking a manager for its commercial first-party property claims unit. The position will involve: Managing commercial first-party property claim associat...
  • 1 Month Ago

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Assistant Store Manager - Garage Clothing - Polaris Fashion Place - Columbus, OH
  • Garage Clothing - Assistant Store Manager -...
  • Columbus, OH FULL_TIME
  • Seize the opportunity to join a global fashion retailer with two brands at the heart of its success, Garage and Dynamite, selected as one of Montreal's Top Employers 2020 and as one of Canada’s Top em...
  • 21 Days Ago

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Legal Intake Specialist - Contact Center (99)
  • Denovo Review
  • Columbus, OH FULL_TIME
  • Leading and innovative plaintiff’s trial law firm is looking for an experienced and charismatic Intake Specialist to join their operations call center team. The Intake Specialist must be experienced i...
  • 1 Month Ago

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0 Medical Claims Review Manager jobs found in Columbus, OH area

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Remote Licensed Clinical Social Worker
  • Headway
  • Westerville, OH
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Professional Counselor
  • Headway
  • Westerville, OH
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Mental Health Counselor
  • Headway
  • Columbus, OH
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Mental Health Therapist
  • Headway
  • Westerville, OH
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Psychiatric Nurse Practitioner
  • Headway
  • Columbus, OH
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Psychiatrist
  • Headway
  • Westerville, OH
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Clinical Social Worker
  • Headway
  • Columbus, OH
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Clinical Psychologist
  • Headway
  • Columbus, OH
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

The confluence of the Scioto and Olentangy rivers occurs just north-west of Downtown Columbus. Several smaller tributaries course through the Columbus metropolitan area, including Alum Creek, Big Walnut Creek, and Darby Creek. Columbus is considered to have relatively flat topography thanks to a large glacier that covered most of Ohio during the Wisconsin Ice Age. However, there are sizable differences in elevation through the area, with the high point of Franklin County being 1,132 ft (345 m) above sea level near New Albany, and the low point being 670 ft (200 m) where the Scioto River leaves...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$95,816 to $122,166
Columbus, Ohio area prices
were up 1.3% from a year ago

Medical Claims Review Manager in Paramus, NJ
Support management with leading Medical Review team to ensure all types of claims requiring medical reviews are completed in compliance with State, Federal, accreditation standards and other applicable regulations.
February 01, 2020
Medical Claims Review Manager in Nashua, NH
By truly combining claims and bill review, the two systems are kept in sync utilizing the scheduled jobs of the aforementioned standard model; however, for real-time data updates, claims examiners are granted access to the entire live bill review system.
January 13, 2020
Medical Claims Review Manager in Davenport, IA
Complex claim errors can only be caught by physician reviewers with the clinical experience to spot mistakes that automated systems can’t detect.
January 03, 2020