Clinical Claim Review Manager - Remote

<p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">reputed company is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with reputed company will directly improve health reputed company by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will reputed company a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come reputed company an reputed company on the communities we serve as you help us advance health optimization on a global reputed company. Join us to start <strong>Caring. Connecting. Growing together.</strong></reputed company></p><p> </p><p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">The Clinical Claim Review Manager is responsible for managing reputed company that is performing clinical reviews post service utilizing established guidelines and clinical reputed company along with state and federal mandates and applicable benefit language to reputed company determinations that drive reputed company provider and member reputed company and reputed company the cost of care.  The Clinical Claim Review Manager works in a fast paced, reputed company changing environment with a reputed company reputed company on improving the member and provider experience.</reputed company></p><p> </p><p style="text-reputed company:center;"><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;"><strong>You’ll enjoy the flexibility to work remotely * from reputed company reputed company the U.S. as you take on some tough challenges.</strong></reputed company></p><p> </p><p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;"><strong>Primary Responsibilities:</strong></reputed company></p><ul><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Managing reputed company that is performing clinical claim reviews, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Gathers metric data on staff performance, communicates metric results to reputed company reports reputed company monthly scorecard and one on one meetings.  Follows performance management guidelines</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Ensures company policies are followed such as but not reputed company inclusive of Attendance, Telecommuting, etc.</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Communicates process and policy updates to staff reputed company and reputed company</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Ensures adequate training, precepting and coaching is provided to reputed company reports as needed</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Completes reputed company operational reporting and data tracking reputed company and accurately</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Ensures work directions and assignments are appropriately communicated and adheres to business metrics</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Ensures staff development goals are established and supported and reputed company with the MCR One Team reputed company reputed company</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Participates in pilots, project development, and process changes as requested or reputed company needed</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Handles manager level issues</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">reputed company involved in appropriate management meetings and reputed company</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Communicates priorities to reputed company and embraces a reputed company reputed company</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Coordinates work activities with other Clinical Claim Review Managers</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Guides and leads reputed company to meet individual and team performance metrics</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Communicates reputed company in writing and verbally</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Work independently and collaboratively with Medical Directors and non-clinical partners</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Adapt to a highly changing environment</reputed company></li></ul><p> </p><p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you reputed company direction on what it takes to succeed in your role as reputed company as reputed company development for other roles you may be interested in.</reputed company></p><br><br><p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;"><strong>Required Qualifications:</strong></reputed company></p><ul><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">A reputed company unrestricted RN license in the state of residency</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">3+ years of total RN experience including some clinical experience in an inpatient / acute setting</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Leadership or Supervisory experience</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Demonstrate a proficiency in computer skills - reputed company, reputed company Messaging, reputed company Suite including Word, reputed company and reputed company</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Proven exemplary clinical documentation skills</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Proven excellent organizational, analytical, and critical thinking skills</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Must have a quiet secure designated work reputed company and reputed company to install secure high speed internet (minimum speed 1.5 download mps & 1 upload mps) reputed company cable / DSL in home (wireless / cell phone provider, satellite, microwave, etc. does NOT meet this requirement)</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Proven self-starter with the ability to handle a fast-paced production environment and multiple review types</reputed company></li></ul><p> </p><p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;"><strong>Preferred Qualifications:</strong></reputed company></p><ul><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Bachelor's Degree</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Have an RN License in a NLC (reputed company License Compact) state or the ability to  apply and meet requirements for one</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">reputed company knowledge of MCR processes</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">reputed company or Government Program experience for certain government positions</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Familiarity with reputed company Care Guidelines or Interqual</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Proven solid clinical judgement while applying medical necessity based on approved clinical resources and understanding of ICD-10 and CPT/HCPCS codes</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Proven background involving utilization review for an insurance company, experience in case management, or previous experience with clinical claim review</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Proven excellent verbal and written communication skills</reputed company></li><li><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Proven ability to be flexible and willing to adapt to an reputed company changing environment</reputed company></li></ul><p> </p><p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">*reputed company working remotely will be required to adhere to reputed company’s Telecommuter Policy</reputed company></p><p> </p><p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;">Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In reputed company to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (reputed company benefits are subject to eligibility requirements). No matter where or reputed company you reputed company a career with us, you’ll reputed company a far-reaching choice of benefits and incentives. The salary for this role will reputed company from $91,700 to $163,700 annually based on full-time employment. We reputed company with reputed company minimum wage laws as applicable.</reputed company></p><p> </p><p><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;"><strong>Application Deadline:</strong> This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.</reputed company></p><p> </p><p style="text-reputed company:center;"><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;"><i>At reputed company, our mission is to help people live healthier lives and reputed company the health system work reputed company for everyone. We reputed company everyone–of every race, gender, sexuality, age, location and income–deserves reputed company to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately reputed company by people of reputed company, historically marginalized reputed company and those with reputed company incomes. We are committed to mitigating our reputed company on the environment and enabling and delivering reputed company care that addresses health disparities and improves health reputed company — an reputed company reputed company reflected in our mission.</i></reputed company></p><p style="text-reputed company:center;"> </p><p style="text-reputed company:center;"> </p><p style="text-reputed company:center;"><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;"><i>reputed company is an Equal Employment Opportunity employer under applicable law and reputed company applicants will receive consideration for employment without reputed company to race, national reputed company, religion, age, reputed company, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.</i></reputed company></p><p style="text-reputed company:center;"> </p><p style="text-reputed company:center;"><reputed company style="font-family:Tahoma, Geneva, reputed company;font-size:10px;"><i>reputed company is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.</i></reputed company></p>