Medical Claims Review Manager jobs in Saint Cloud, MN

Hours: M-F 8a-4:30p  NO Remote Work

WeCare is actively seeking a Utilization Review Advocate. This vital role is central to our commitment to delivering exceptional care and support. The ideal candidate will be responsible for overseeing various aspects of utilization management, ensuring adherence to service standards, and collaborating across departments to promote efficient, person-centered care. A key component of this role includes the management of billing reviews and the diligent follow-up on claims denials.

Duties to include:

• Monthly audit of client medical coverage to ensure continuation of services.
• Processes patient authorizations, denials, and appeals.
• Conduct billing reviews and actively follow up on claims denials to ensure accurate and timely reimbursement.
• Issues denial letters in accordance with policies, procedures, and regulatory guidelines.
• Identifies documentation deficiencies, admission & Intake screening issues, appropriate service enrollment issues contributing to payment denials.
• Completes paperwork to obtain prior authorizations to ensure coverage and continuation of services.
• Participate in pre-screening of new referrals, perform intakes & coordinate with other departmental services for handoff.
• Perform Navigation Services via MNsure to connect new referrals and current clients that have lapsed with benefits to ensure continued care.
• Performs thorough & accurate documentation in all aspects of daily duties.
• Collaborates with client coordinator and other teams as needed to expedite timely resolution of situations to include inappropriate admissions, inappropriate service enrollment issues and with questions regarding appropriate utilization management.
• Back-up the client coordinator as needed.
• Performs other job-related duties as assigned.

Requirements:

• Associates or higher in Behavioral Health, Social Work, Psychology or Casework Management
• Must be proficient in MS Office Suite
• Confident with utilization of Electronic Health Record (EHR) systems
• Must be able to clear a Minnesota Department of Human Services Background Check