Medical Claims Review Manager jobs in the United States

How YOU will make a Difference:  

The Medical Claims Review Nurse provides monitoring of member utilization and claim patterns using clinical nursing knowledge and coding expertise to oversee the accuracy of claims for medically necessary care provided to our members.  This work promotes the integrity of claim payment to support fiscal responsibility of payments. This nurse also works in conjunction with the Appeals team providing clinical expertise and performs high-level writing skills.  

What you will do:

• Analyzes claims against clinical documentation using coding and clinical expertise
• Clinical  support of the Hospital Bill Review process
• Retrospective utilization management case review
• Extrapolates and summarizes medical information for medical director and other external entities
• Ensures that reviews and appeals are resolved timely to meet regulatory timeframes
• Generates written correspondence to providers, members, brokers and clients

Knowledge, Experience, and Key Attributes needed for Success:  

• Current Baccalaureate prepared (Preferred) 
• Active RN clinical license
• Current Certified Professional Coder certificate (preferred)
• Experience in the application of common coding and billing standards including the American Medical Association CPT (Current Procedural Terminology), the Centers for Medicare and Medicaid Services National Correct Coding Initiative, Optum Coding resource manuals, the UB04 Billing Manual coding guidelines and the National Uniform Billing Committee 
• 3-5 years of clinical nursing experience
• Knowledge of Utilization Review processes 
• Knowledge of the medical plan appeal process (preferred)
• Strong experience in clinical practice with diverse diagnoses
• Problem solving and critical thinking skills
• Excellent verbal and written communication skills
• Proficiency with Microsoft Office applications (Outlook, Word, DOSS)
• Ability to be self-motivated and self-directed
• Enjoys the pace and rhythm of a deadline-oriented environment with strong prioritization skills 
• Behavioral health experience (Preferred)

Compensation
The base salary range for this position in the greater Seattle area is $85,000 - $108,000 and varies dependent on geography, skills, experience, education, and other job or market-related factors. Performance-based incentive bonus(es) is available. In addition, HMA provides a generous total rewards package for full-time employees that includes: seventeen (IC) days paid time off; eleven paid holidays, one paid personal and one paid volunteer day; company-subsidized medical, dental, vision, and prescription insurance; company-paid disability, life, and AD&D insurances; voluntary life insurances; HSA and FSA pre-tax programs; 401(k)-retirement plan with company match; wellness incentive and reimbursement; remote work and continuing education reimbursements; discount program; parental leave; and a charitable giving match. For more information about HMA, visit www.accesshma.com. 

Disclaimer: The salary, other compensation, and benefits information are accurate as of this posting date. HMA reserves the right to modify this information at any time, subject to applicable law.

How we Support your Work, Life, and Wellness Goals

We offer a comprehensive total rewards package including: competitive pay; annual incentive; medical, dental, and vision insurance; 401K retirement plan with match; generous PTO and holidays; an onsite gym facility; a gym subsidy; Life, AD&D, Short-Term and Long-Term Disability Insurances; an Employee Assistance Plan; free parking and easy freeway access to I-405 and I-520; a well-stocked kitchen on-site with subsidized snacks and refreshments; year-round wellness activities; the ability to earn a $500 wellness incentive; monthly events; paid volunteer hours and more!

HMA requires a background screen prior to employment.

Protected Health Information (PHI) Access Healthcare Management Administrators (HMA) employees may encounter protected health information (PHI) in the regular course of their work. All PHI shall be used and disclosed on a need-to-know-basis and according to HMA’s standard policies and procedures.

HMA is an Equal Opportunity Employer