Medical Claims Review Manager jobs in Portsmouth, NH

PMC Medical Group, a well-established independently owned multi-disciplinary practice, is seeking a full-time Utilization Review Specialist.

Summary: Provide comprehensive assessment, planning, implementation, and evaluation of individual patient care needs. Coordinate and promote continuity of care and cost effectiveness through the functions of case management, utilization review and authorization management.

Essential Functions:

• Communicate with providers regularly throughout patient care and develop an effective working relationship
• Maintain current knowledge of insurance medical policies guidelines to ensure providers remain in compliance, documentation meets criteria, and patients requiring services meet required guidelines
• Ensure the medical practice is complying with state, federal and company based regulations and policies
• Ensure that patient procedures are appropriate, necessary, and carried out within the established timeframe
• Review insurance criteria to ensure patients and providers are not exceeding insurance limits
• Assist providers to maintain appropriate cost, case, and desired patient outcomes
• Collaborate with clinical staff in the development and execution of the plan of care and achievement of goals
• Verify patient insurance benefits
• Obtain authorization from insurance carriers for medically necessary procedures
• Promote effective and efficient utilization of clinical resources
• Mobilize resources to achieve expected goal to assist in achieving desired clinical outcomes within the desired timeframe
• Initiate and present “denial letters” as appropriate
• Serve as a patient advocate. Enhance a collaborative relationship to maximize the patient’s and family’s ability to make informed decisions. Explain to patient any out of pocket costs for procedures or services.

Education/Experience Requirements

• High School diploma or equivalent
• 1-2 years prior medical office experience
• Effective communication skills, both verbal and written; strong computer and typing skills; comfortable with web-based insurance portals; customer service; familiarity with Windows based programs; familiarity with office equipment; time management skills; multi-tasking skills; ability to handle difficult situations and work under pressure; ability to collaborate and communicate within all levels of the organization.

Pay dependent upon on education and past experience.

As a team member at PMC Medical Group, you’ll enjoy:

• 9 Paid Holidays per year
• Accrued PTO
• Medical Benefits via an Individual Coverage Health Reimbursement Account (ICHRA)
• Dental
• Life Insurance & Disability
• 401k