Medical Claims Review Manager jobs in the United States

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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External Quality Review (EQR) Contract Manager
  • Medical Review of North Carolina
  • Raleigh, NC FULL_TIME
  • External Quality Review (EQR) Contract Manager

    Remote Employment

    Who We Are:

    Constellation Quality Health is a non-profit health care quality consultancy and QIO-like Entity certified by Centers for Medicare and Medicaid Services (CMS) founded by physicians in 1983. Headquartered in North Carolina’s Research Triangle, we offer an array of quality improvement, clinical review, audit, technical, and consulting services and solutions to improve care delivery, system performance, and patient outcomes.

    What You’ll Do:

    We are seeking an External Quality Review (EQR) Contract Manager to be responsible for the effective and efficient operation of assigned contracts and services. This position plays a key role assisting with identification and capitalizing on business opportunities and providing maximum value to the customer!

    We expect you to:

    • Serve as a leader and professional role model to support Constellation Quality Health’s drive into the future.
    • Oversee and coordinate all contract/business activities, ensuring customer deliverables are met and of the highest quality.
    • Develop, train, and cross-train contract staff; monitor productivity, schedules, volume, quality and accuracy of end products and reports, timeliness of deliverables; and address performance issues as needed.
    • Act as primary contact, meeting facilitator, and resource for contractual questions/discussions.
    • Analyze program systems and processes to identify opportunities for efficiencies and develop solutions.
    • Develop and manage budgets.
    • Provide subject matter expertise for service line proposals.

    This is a remote work opportunity for the right candidate!

    Who You Are:

    The successful incumbent candidate will be a leader who maintains professional working relationships with health plans, state Medicaid agency contract staff and program leaders, and all internal and external customers. This management position will proactively identify and assist with the development of plans and activities to expand EQR contract opportunities; and provide maximum value to the customers. Responsibilities include monitoring contract performance, identifying future business opportunities, developing process improvements and enhancements, and establishing operational workflows and procedures for the EQR service line.

    Our requirements for this role:

    • Bachelor’s degree required; Master’s degree preferred; ten (10) years of related experience
    • CPHQ or other advanced certification (Project Management, HEDIS, Utilization Management, etc.) required
    • Five (5) years’ experience in related contract work and/or quality management in a leadership capacity.
    • Minimum five (5) years of supervisory experience, managing diverse teams
    • Experience managing and utilizing data to identify risks, trends, gaps, and opportunities
    • Knowledge of MCO and/or PIHP delivery systems and current trends
    • Experience with Medicaid populations, programs, and policies
    • Experience with Medicaid managed care
    • Excellent communication skills to include developing training materials, website postings, and newsletter outlines
    • Experience in Quality Management and Performance Improvement methodologies
    • Experience writing professional reports
    • Experience with Utilization Management, Case Management, Managed Care networks, Claims/Appeals, and/or Population Health
    • Knowledge of URAC and/or NCQA accreditation standards or certification a plus
    • Excellent communication skills, both written and oral
    • Experience making professional presentations to large audiences
    • Ability to function independently and coordinate review activities
    • Proficiency with Microsoft Office Products, including Word, PPT, Excel, etc.

    Why Constellation Quality Health?

    We offer a competitive salary and benefits package and a flexible, supportive hybrid work environment.

    Equal opportunity employer of protected veterans

    Equal opportunity employer of individuals with disabilities

    We do not discriminate on the basis of race, ancestry, color, religion, sex, age, marital status, sexual orientation, gender identity, national origin, medical condition, disability, veteran status, or any other basis protected by law.

    Applicants and employees are protected from discrimination based on inquiring about, disclosing, or discussing compensation or the compensation of other applicants or employees.

  • 7 Days Ago

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Clinical Program Manager, Healthcare Review Services
  • Managed Medical Review Organization, Inc.
  • Novi, MI FULL_TIME
  • Job Summary The Clinical Program Manager, Healthcare Review Services shall be responsible for the oversight of the Healthcare Review service line. The CPM shall be responsible for day-to-day employee,...
  • 27 Days Ago

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Healthcare Claims Quality Assurance Manager - Medical Review Expert
  • Get It Recruit - Healthcare
  • Rockville, MD FULL_TIME
  • About The RoleYou will play a vital role in ensuring the quality and accuracy of healthcare claims at a leading organization dedicated to advancing health equity, expanding coverage, and improving hea...
  • 19 Days Ago

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Manager - Peer Review
  • Peer Review - the Association Careers
  • Durham, NC FULL_TIME
  • About the Role: As a Manager in our Peer Review Team, you will obtain and evaluate data to identify educational opportunities for public accounting firms, peer reviewers, and others involved in admini...
  • 18 Days Ago

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Clinical Program Manager
  • Managed Medical Review Organization, Inc.
  • Novi, MI FULL_TIME
  • Company Description Managed Medical Review Organization, Inc. (MMRO) in Novi, MI, is a renowned provider of disability and medical review services to various sectors, including disability carriers, go...
  • 23 Days Ago

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Medical Director, Medical Claims Review - Remote
  • UnitedHealth Group
  • Minneapolis, MN FULL_TIME
  • Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connectin...
  • 7 Days Ago

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Licensed Psychiatrist
  • Headway
  • Columbus, OH
  • Remote Licensed Psychiatrist Wage: Between $119-$239 an hour Are you a licensed Psychiatrist looking to launch a private...
  • 10/31/2024 12:00:00 AM

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Licensed Mental Health Counselor
  • Headway
  • Columbus, OH
  • Remote Licensed Mental Health Counselor (LMHC) Wage: Between $90-$127 an hour Are you a Licensed Mental Health Counselor...
  • 10/31/2024 12:00:00 AM

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Licensed Clinical Psychologist
  • Headway
  • Columbus, OH
  • Remote Licensed Clinical Psychologist Wage: Between $90-$174 an hour Are you a Licensed Clinical Psychologist looking to...
  • 10/31/2024 12:00:00 AM

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Licensed Marriage and Family Therapist
  • Headway
  • Columbus, OH
  • Remote Licensed Marriage and Family Therapist (LMFT) Wage: Between $90-$127 an hour Are you a Licensed Marriage and Fami...
  • 10/31/2024 12:00:00 AM

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Licensed Clinical Social Worker
  • Headway
  • Columbus, OH
  • Remote Licensed Clinical Social Worker (LCSW) Wage: Between $90-$127 an hour Are you a Licensed Clinical Social Worker l...
  • 10/31/2024 12:00:00 AM

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Licensed Professional Counselor
  • Headway
  • Columbus, OH
  • Remote Licensed Professional Counselor (LPC) Wage: Between $90-$127 an hour Are you a Licensed Professional Counselor lo...
  • 10/31/2024 12:00:00 AM

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Licensed Mental Health Therapist
  • Headway
  • Columbus, OH
  • Remote Licensed Mental Health Therapist (LMHT) Wage: Between $90-$127 an hour Are you a Licensed Mental Health Therapist...
  • 10/31/2024 12:00:00 AM

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LICENSED PROFESSIONAL CLINICAL COUNSELOR
  • FARRELL NELSON SERVICES INC
  • Columbus, OH
  • Job Description Job Description Well established private practice located near downtown Columbus is looking for a full o...
  • 10/28/2024 12:00:00 AM

Income Estimation for Medical Claims Review Manager jobs
$98,921 to $126,124