Manager Claims Clinical Review

Hires, trains and develops staff to assure appropriate coverage and support in the areas of his/her responsibility in order to meet established SCAN guidelines and regulatory requirements.
Takes appropriate corrective action, disciplines and counsels subordinates as needed to meet established goals and objectives.
Stays current on SCAN systems and procedures related to the interface of the Cost Containment functions with claim examiners and claim supervisors.
Develops policies and procedures for subordinates, including development of quality and production standards.
Oversees and directs staff in preparing claims for reinsurance filing and periodic regulatory audits.
Oversees and directs staff in compiling inventory reports and other reports as required.
Directs staff in performing audits of medical claim per established criteria, identify need for medical record review, necessary documentation to support decision making process regarding appropriateness of claim, billed charges, benefit coverage.
Direct training staff in the development and administration of department level training programs.
Conduct retrospective review of ER claims that do not need auto pay criteria.
Review potential claims denials in conjunction with Medical Director.
Work independently with Medical Director to discuss issues pursuant to adjudication of claims and post service appeals.
Assist in the analysis of CHDR overturns and make recommendations for future case consideration.
Perform other job-related functions as requested.

Job Requirements



Current licensure as a Registered Nurse in the State of California is required.
Minimum of three (3) years clinical experience in an acute setting and medical record review.
Minimum five (5) years experience and background in managed care customer service, and claims/audit experience required; with minimum 2+ years of supervisory experience preferably at the manager level .
Strong interpersonal skills, including excellent written and oral communication skills; strong commitment to detail.
Demonstrated leadership and management skills.
Proficient in multiple software packages; MS Word, Excel, and Access preferred. Knowledge of managed care for both the Senior and Commercial population.
Experience/knowledge in the Appeals/ claims processing procedure in Managed Care or similar experience.
Working knowledge of the Managed Care regulatory agencies and the applicable laws and regulations.