Medical Claims Review Manager jobs in South Carolina

External Quality Review (EQR) Specialists

Part-time As Needed

Remote

Who We Are:

Constellation Quality Health, formerly CCME, is a non-profit health care quality organization and QIO-like Entity certified by the Centers for Medicare & 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 Quality Review Specialists (specialists) to conduct external quality review activities as determined by health care quality review contracts. The specialists are responsible for timely interpretation and analysis of information provided to support contract compliance and quality improvement while maintaining positive professional working relationships with contract staff, program leaders, and health plans.

We expect you to:

• Assist with development of methodologies and data collection tools.
• Conduct desk and onsite document and program reviews.
• Interview staff during onsite visits and provide technical assistance as needed.
• Develop reports inclusive of findings and recommendations
• Providing technical expertise based on assessment and contract requirements.
• Provide maximum value to the customer.
• Serve as a positive and supportive team member.
• Stay abreast of EQR requirements, state and federal regulations.
• Works part-time on an as needed basis

Position works remotely; however, some travel may be required. Candidates in South Carolina and North Carolina are preferred.

Who You Are:

The successful candidate meets the following requirements:

• Bachelor’s Degree from an accredited college or university in related field with at least 3-5 years of related experience.
• Certified Professional Healthcare Quality (CPHQ), Certified Fraud Examiner or Clinical Licensure preferred.
• Knowledge of Medicaid managed care delivery systems and current healthcare trends
• Experience with Medicaid populations, programs, and policies.
• Experience with Medicaid managed care or healthcare compliance.
• Excellent communication skills to include report writing, development and delivery of content for health plan or provider education.
• Experience in quality management and improvement methodologies.
• Knowledge of URAC or NCQA accreditation standards and/or HEDIS certification a plus.
• Knowledge of claims, credentialing, appeals & grievances a plus.

Why Constellation Quality Health

We offer a flexible, supportive 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.