Medical Claims Review Manager jobs in Denver, CO

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
  • Denver, CO 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.

  • 23 Days Ago

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Physician Telecommute Medical Review Stream
  • Concentra
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified physician in one of the below specialties? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Emergency Medicine Internal Medici...
  • 1 Month Ago

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Physician Telecommute Medical Review Stream
  • Concentra Career Choice
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified physician in one of the below specialties? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Emergency Medicine Internal Medici...
  • 1 Month Ago

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Neurosurgeon Telecommute Medical Review Stream
  • Concentra Career Choice
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified Neurosurgeon? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Are you passionate about your work/life balance? We are seeking...
  • 12 Days Ago

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Neurosurgeon Telecommute Medical Review Stream
  • Concentra, Inc
  • Denver, CO FULL_TIME
  • Neurosurgeon Telecommute Medical Review Stream Location US-CO-Denver Job ID 284635 Pos. Category Medical - Medical Review - UR Pos. Type Contract Overview Are you an accomplished Board Certified Neuro...
  • 12 Days Ago

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RN, RN - Utilization Management/Review - Travel
  • Excel Medical Satffing
  • Aurora, CO FULL_TIME
  • Details Travel Job Type RN Profession RN - Utilization Management/Review Specialty Shift Details 08:00 AM - 05:00 PM Shift Job Order Details 06/20/2022 Start Date 09/17/2022 End Date 13 Week(s) Durati...
  • 1 Month Ago

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0 Medical Claims Review Manager jobs found in Denver, CO area

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Remote Licensed Addiction Counselor (LAC) - Colorado
  • Headway
  • Denver, CO
  • Are you a Licensed Addiction Counselor (LAC) in Colorado in South Dakota looking to launch a private practice, or grow y...
  • 5/8/2024 12:00:00 AM

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Remote Licensed Clinical Addiction Specialist (LCAS) - North Caroline
  • Headway
  • Denver, CO
  • Are you a Licensed Clinical Addiction Specialist (LCAS) in North Carolina looking to launch a private practice, or grow ...
  • 5/8/2024 12:00:00 AM

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Remote License Professional Counselor of Mental Health (LPCMH) - Delaware
  • Headway
  • Denver, CO
  • Are you a License Professional Counselor of Mental Health (LPCMH) in Delaware in South Dakota looking to launch a privat...
  • 5/8/2024 12:00:00 AM

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Remote Licensed Alcohol and Drug Counselor (LADC-I) - Massachusetts
  • Headway
  • Denver, CO
  • Are you a Licensed Alcohol and Drug Counselor (LADC-I) in Massachusetts in South Dakota looking to launch a private prac...
  • 5/8/2024 12:00:00 AM

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Remote Certified Substance Abuse Counselor (CSAC) - Hawaii
  • Headway
  • Denver, CO
  • Are you a Certified Substance Abuse Counselor (CSAC) in Hawaii looking to launch a private practice, or grow your existi...
  • 5/8/2024 12:00:00 AM

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Remote Clinical Mental Health Counselor (CMHC) - Utah
  • Headway
  • Denver, CO
  • Are you a Clinical Mental Health Counselor (CMHC) in Utah in South Dakota looking to launch a private practice, or grow ...
  • 5/8/2024 12:00:00 AM

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Child/Adolescent Psychiatrist- Private Practice **Hybrid and Part Time options** - Denver, CO
  • LifeStance Health
  • Denver, CO
  • We are actively looking to hire talented Child Psychiatrists in the area, who are passionate about patient care and comm...
  • 5/6/2024 12:00:00 AM

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TMS/Ketamine Psychiatrist
  • Serenity Healthcare
  • You may be eligible to join a team of forward-thinking Interventional Psychiatrists in one of many major metropolitan ar...
  • 5/6/2024 12:00:00 AM

Denver is in the center of the Front Range Urban Corridor, between the Rocky Mountains to the west and the High Plains to the east. Denver's topography consists of plains in the city center with hilly areas to the north, west and south. According to the United States Census Bureau the city has a total area of 155 square miles (401 km2), of which 153 square miles (396 km2) is land and 1.6 square miles (4.1 km2) (1.1%) is water. The City and County of Denver is surrounded by only three other counties: Adams County to the north and east, Arapahoe County to the south and east, and Jefferson County...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$99,561 to $126,941
Denver, Colorado area prices
were up 0.4% 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