Medical Claims Review Manager jobs in Melbourne, FL

SCOPE:

Under general supervision of the Program Manager (PM) and reporting to the PM, the Medical Review Nurse (MRN) is responsible for the initial chart review and chart case management for medical exam/screening programs to verify that all medical information and exam components are accurate. The RN works directly with Physicians and Examinees to ensure all medical information is gathered and performs medical Quality Assurance on all charts in various process stages leading to a final determination.

This is an in-office position.

LOCATION: Candidate must be local to the Cape Canaveral, Florida area.

The salary for this position is $66,560 - $70,000.

DUTIES AND RESPONSIBILITIES:

• Performs medical review of incoming charts to determine if additional medical information is needed.
• Collaborates with Physician(s) and other internal nursing staff members for chart review.
• Performs medical Quality Assurance (QA) on all charts in various process stages.
• Interfaces with Client's Medical Department as well as the on-site provider.
• Contacts Examinee via telephone or email to clarify information necessary to complete the chart.
• Develops a very good understanding of the specific contract's guidelines and addendums as required.
• Masters the various software programs specific to the functioning of the exam program.
• Implements and follows up on requests for further evaluation from the Examinee when required.
• Works closely with other departments to provide accurate and quality outcomes.
• Thoroughly cognizant of metrics and organizes workload to meet them.
• Consistently learns and applies codified state and federal regulations specific to particular contract(s).

OTHER DUTIES:

• Serve as backup to other nurses for daily duties, and assists with follow-up calls to facilities and Examinees as needed as well as other duties as assigned.
• Opportunity to travel and assist on medical mobile events as either a site lead and/or RN as work or personal schedule permit.
• May participate in interdepartmental project groups or task forces to integrate activities, communicate issues, obtain approvals, resolve problems and maintain a specific level of knowledge pertaining to new developments, new task efforts, contract awards, and new policy requirements.
• Supports marketing and sales objectives and efforts as requested.
• Performs duties in a safe manner. Follows the corporate safety policy. Participates and supports safety meetings, training, and goals. Ensures safe operating conditions within an area of responsibility. Encourages co-workers to work safely. Identifies "close calls" and/or safety concerns to supervisory personnel. Maintains a clean and orderly work area.
• Assists in the active implementation of company initiatives to ensure compliance with OSHA VPP, ISO, JCAHO, AAAHC, and other mandated regulations/standards.
• May serve on the OSHA VPP, Safety, and Wellness Committees.

BASIC QUALIFICATIONS:

• 5-7 years of relevant experience.
• Fully unencumbered nursing license required.
• Proficiency with computer and common office equipment, as well as with MS Office products.
• Must be able to multitask, be flexible, be organized, and have excellent oral and written communication skills as well as exceptional attention to detail.

PREFERRED QUALIFICATIONS:

• COHN-S and/or, CAOHC certifications.
• Bachelor's Degree with 5 years of relevant experience.
• Flexibility and availability to travel and assist to support medical mobile events as either site lead and/or RN.

PHYSICAL REQUIREMENTS:

• Work is normally performed in a typical interior/office work environment.
• Work involves sitting and standing for prolonged periods of time.
• May require bending and lifting up to 15 lbs.
• Constant use of computer and common office equipment required.

Acuity International is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration without regard to race, color, sex, national origin, age, protected veteran status, or disability status.

For OFCCP compliance, the taxable entity associated with this job posting is: