Medical Claims Review Manager jobs in Summerville, SC

RN Case Manager Full Time Days Position Summary

Facilitates and supports an effective Utilization Review program within the Case Management department, which may be centralized within a specific market or group. The position has overall responsibility to ensure care is provided at the appropriate level of care based on medical necessity and assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. The position manages medical necessity process for accurate and timely payment for services which my require negotiations with a payer on a case-by-case basis. The Utilization Review Manager integrates national standards for case management scope of services.

Responsibilities

Manages the Utilization Review/Central Utilization Review department to include hiring, training, managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with other departments. Accountable for compliance with state and federal regulatory requirements, accreditation standards and Tenet policy. Provides education to physicians, physician advisors, Case Management staff, and other hospital leaders. Identifies and provides physician education and feedback on hospital utilization and disputes/denials data. Maintains knowledge of current contractual agreements. Organizes the concurrent authorization process to meet utilization management needs and monitor turn-around times to meet health plan requirements. Implements and monitors processes to prevent payer disputes. Ensures medical necessity and revenue cycle processes are completed accurately and in compliance with Tenet policy as well as any state or federal program requirements.

THE RN CASE MANANAGER FULL TIME DAYS CANDIDATE WILL POSSESS THE FOLLOWING EDUCATION, LICENSE/CERTIFICATIONS, AND EXPERIENCE.

Education

Certification