Medical Claims Review Manager jobs in Springfield, OR

Job Summary:

• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
• Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards.
• Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
• Abstracts data from records and maintains

Educational/Licensure:

• Current Oregon RN license
• Knowledge in areas such as InterQual Level of Care Criteria and Milliman & Robertson Criteria as well as knowledge of third party payer regulations related to utilization and quality review is also preferred.

Qualifications:

• Significant experience in the healthcare field is required including a minimum of five years as a clinical nurse in an acute care setting. In addition, having at least five to seven years of experience in case management, discharge planning, and/or utilization review is preferred.
• Knowledge of regulatory and payer requirements for Case Management Activities.
• Ability to critically evaluate and make decisions about whether discharge planning for highly difficult cases.

Education

• Bachelors or better in Nursing

Licenses & Certifications

• L-OR-RN License