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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Job Type:
Per DiemScheduled Hours:
0Work Shift:
Day (United States of America) Joint role of Case Manager and Utilization Review NurseJob Description:
The Inpatient Registered Nurse (RN) Case Manager for Hospital at Home Care Transitions coordinates utilization review, discharge planning and monitors quality assurance for Lahey Clinic inpatient admissions. Leads the multidisciplinary team to ensure a timely process. Registered Nurses (RNs) with utilization review experience, case management experience, and med/surg experience are encouraged to apply.
Essential Duties & Responsibilities including but not limited to:
1) Performs utilization review and discharge planning to inpatient admissions.
2) Applies Interqual, AEP and or other review criteria approved by the Clinic to accurately determine appropriateness for inpatient and outpatient care.
3) Utilizes clinical expertise to determine the appropriate level of care for patients. Leads the healthcare team in selecting appropriate, safe, hospital or alternative care options.
4) Works closely with Community Case Managers to collaborate regarding medically fragile and or high risk patients admitted to the clinic.
5) Identifies delay days and notifies Team Leader.
6) Reports serious occurrences and sentinel events to Risk Management.
7) Works with patients and families to facilitate post hospital care and develop plans to meet short and long-term needs.
8) Accurately manages observation status patients by working with physicians to ensure appropriate utilization.
9) Is part of the department’s Saturday, Sunday, holiday and beeper rotation as needed.
10) Supports all service line activities related to utilization and quality management.
11) Assists in the development and implementation of clinical pathways.
12) Adheres to all insurance, contractual and regulatory requirements as mandated.
13) Works with Lahey Clinic nursing, social work and other members of the healthcare team to coordinate and facilitate patient discharge.
14) Works with the Post Acute Care Coordinator to facilitate timely patient access to post acute care Services.
15) Participates in hospital or medical committees representing patient issues and department functions such as case management, utilization and CQI as requested.
16) Incorporates Lahey Clinic Guiding Principles , Mission Statement and Goals into daily activities.
17) Complies with all Lahey Clinic Policies.
18) Complies with behavioral expectations of the department and Lahey Clinic.
19) Maintains courteous and effective interactions with colleagues and patients.
20) Demonstrates an understanding of the job description, performance expectations, and competency assessment.
21) Demonstrates a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.
22) Participates in departmental and/or interdepartmental quality improvement activities.
23) Participates in and successfully completes Mandatory Education.
17) Performs all other duties as needed or directed to meet the needs of the department.
Minimum Qualifications:
Experience:
FLSA Status:
Non-ExemptClear All
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