Medical Claims Review Manager jobs in Arvada, CO

Medical Claims Review Manager oversees the performance, productivity, and quality of the medical claims review staff. Responsible for hiring, training, and firing medical claims review staff. Being a Medical Claims Review Manager evaluates medical claims review processes and recommends process improvements. Serves as a technical resource for all medical review workers. Additionally, Medical Claims Review Manager typically requires an RN or BSN. Requires a bachelor's degree. Typically reports to a head of a unit/department. The Medical Claims Review Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. Extensive knowledge of department processes. To be a Medical Claims Review Manager typically requires 5 years experience in the related area as an individual contributor. 1 to 3 years supervisory experience may be required. (Copyright 2024 Salary.com)

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RN Medical Claims Review Nurse (Remote)
  • Morgan Stephens
  • Denver, CO FULL_TIME
  • Medical Claims Review Nurse
    Position is fully remote
    Schedule: M-F 9AM-5PM local time. The training schedule will be M-F 9AM-5PM EST.
    Daily responsibilities: Candidates will be reviewing medical patient records against standard medical criteria.
    Candidates MUST have 3 years of clinical appeals experience along with 1 year of utilization review experience. Candidates with DRG experience on the resume will be prioritized for interviews.

    JOB SUMMARY:
    • Performs clinical/medical reviews of retrospective medical claim reviews, medical claims and previously denied cases, in which an appeal has been submitted, to ensure medical necessity and appropriate/accurate billing and claims processing.
    • Identifies and reports quality of care issues.
    • Identifies and refers members with special needs to the appropriate healthcare organization program per
    policy/protocol.
    • Assists with Complex Claim review; requires decision making pertinent to clinical experience
    • Documents clinical review summaries, bill audit findings and audit details in the database
    • Provides supporting documentation for denial and modification of payment decisions
    • Independently re-evaluates medical claims and associated records by applying advanced clinical knowledge, knowledge of all relevant and applicable Federal and State regulatory requirements and guidelines, knowledge of healthcare organization policies and procedures, and individual judgment and experience to assess the appropriateness of service provided, length of stay and level of care.
    • Reviews medically appropriate clinical guidelines and other appropriate criteria with Medical Directors on denial decisions.
    • Supplies criteria supporting all recommendations for denial or modification of payment decisions.
    • Serves as a clinical resource for Utilization Management, Chief Medical Officers, Physicians, and
    Member/Provider Inquiries/Appeals.
    • Provides training, leadership and mentoring for less experienced clinical peers and LVN, RN and
    administrative support staff.
    • Resolves escalated complaints regarding Utilization Management and Long Term Services & Supports
    issues.
    • Identifies and reports quality of care issues.
    • Prepares and presents cases in conjunction with the Chief Medical Officers Medical Directors for
    Administrative Law Judge pre-hearings, State Insurance Commission, and Meet and Confers.
    • Represents the healthcare organization and presents cases effectively to Judicial Fair Hearing Officer during Fair Hearings as may be required.

    JOB FUNCTION:
    Responsible for administering claims payments, maintaining claim records, and providing counsel to claimants regarding coverage amount and benefit interpretation. Monitors and controls backlog and workflow of claims. Ensures that claims are settled in a timely fashion and in accordance with cost control standards.

    REQUIRED EDUCATION:
    Highschool Diploma or GED

    REQUIRED EXPERIENCE:
    Minimum three years clinical appeals review experience.
    Minimum one year Utilization Review

    REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:
    Active, unrestricted State Registered Nursing (RN) license in good standing.

  • 10 Days Ago

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Physician Telecommute Medical Review Stream
  • Concentra
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified physician in one of the below specialties? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Emergency Medicine Internal Medici...
  • 21 Days Ago

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Physician Telecommute Medical Review Stream
  • Concentra Career Choice
  • Denver, CO OTHER
  • Overview Are you an accomplished Board Certified physician in one of the below specialties? Candidates must have a CO license and a Level 1 or Level 2 Accreditation. Emergency Medicine Internal Medici...
  • 21 Days Ago

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Peer Review Program Manager
  • AdventHealth Rocky Mountain
  • Littleton, CO FULL_TIME
  • Description All the benefits and perks you need for you and your family: Benefits from Day One Paid Days Off from Day One Student Loan Repayment Program Career Development Whole Person Wellbeing Resou...
  • 19 Days Ago

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RN, RN - Utilization Management/Review - Travel
  • Excel Medical Satffing
  • Aurora, CO FULL_TIME
  • Details Travel Job Type RN Profession RN - Utilization Management/Review Specialty Shift Details 08:00 AM - 05:00 PM Shift Job Order Details 06/20/2022 Start Date 09/17/2022 End Date 13 Week(s) Durati...
  • 23 Days Ago

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Medical Claims Processor
  • Zenith American
  • Arvada, CO OTHER
  • Title: Medical Claims Processor Department: Claims Bargaining Unit: UFCW 1546 Grade: 23 Position Type: Non-exempt Hours per Week: 40 Date Posted: 11/29/2023 Position Summary The Medical Claims Process...
  • 16 Days Ago

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0 Medical Claims Review Manager jobs found in Arvada, CO area

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Remote Licensed Psychiatrist
  • Headway
  • Arvada, CO
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Marriage and Family Therapist
  • Headway
  • Arvada, CO
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Psychiatric Nurse Practitioner
  • Headway
  • Arvada, CO
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Mental Health Therapist
  • Headway
  • Arvada, CO
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Clinical Psychologist
  • Headway
  • Arvada, CO
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Professional Counselor
  • Headway
  • Arvada, CO
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Mental Health Counselor
  • Headway
  • Arvada, CO
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

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Remote Licensed Clinical Social Worker
  • Headway
  • Arvada, CO
  • Mental health clinicians use Headway in a number of ways, ranging from conducting psychotherapy sessions with patients t...
  • 4/25/2024 12:00:00 AM

Arvada /ɑːrˈvædə/ is a Home Rule Municipality in Jefferson and Adams counties, a part of the Denver-Aurora-Lakewood, CO Metropolitan Statistical Area of the U.S. state of Colorado. As of the 2010 census the population was 106,433, and in 2016 the estimated population was 117,453, ranking Arvada as the seventh most populous municipality in Colorado. The Olde Town Arvada historic district is 7 miles (11 km) northwest of the Colorado State Capitol in Denver. Arvada is located in northeastern Jefferson County at 39°49′12″N 105°6′40″W / 39.82000°N 105.11111°W / 39.82000; -105.11111 (39.819962, -...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$99,328 to $126,645
Arvada, Colorado area prices
were up 0.4% from a year ago

Medical Claims Review Manager in Paramus, NJ
Support management with leading Medical Review team to ensure all types of claims requiring medical reviews are completed in compliance with State, Federal, accreditation standards and other applicable regulations.
February 01, 2020
Medical Claims Review Manager in Nashua, NH
By truly combining claims and bill review, the two systems are kept in sync utilizing the scheduled jobs of the aforementioned standard model; however, for real-time data updates, claims examiners are granted access to the entire live bill review system.
January 13, 2020
Medical Claims Review Manager in Davenport, IA
Complex claim errors can only be caught by physician reviewers with the clinical experience to spot mistakes that automated systems can’t detect.
January 03, 2020