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Clinical Claims Review - RN Manager Job

Full Job Title: Registered Nurse Manager Clinical Claims Review

Job Number: 1706096

Location: Tampa, FL

Date Posted: 6-13-2018

Location: Henderson Rd, Tampa, FL 33634
Department: Health Services
Reports to: Sr. Director, Strategic Initiatives

This position is responsible for overseeing the claim review team and processes to ensure accurate and timely completion of medical record and claim reviews in accordance with coverage, coding, and utilization of services and practice guidelines.

Essential Functions:
  • Accountable for the proper administration of the clinical claims processing function. Manage department productivity. Meet coding and payment accuracy standards. Reduce claims turnaround time to meet industry best practice benchmarks and company goals.
  • Ensure that claims are processed in accordance with reimbursement guidelines. Develop and implement processes that ensure accurate claim processing. Responsible for maintenance of applicable Claims Policies and Procedures.
  • Responsible for process improvement within the clinical claims department and working with other departments to improve interdepartmental processes impacting the clinical claims workflows and productivity.
  • Provides leadership to the team including communication on priorities, company strategy, and department goals. Responsible for training, hiring, development, and performance management of direct reports.
  • Work cross-functionally to improve auto-adjudication and eliminate the manual processing of claims where possible. Identify changes in xcelys configuration, workflow, and security needed to improve claim processing.
  • Responsible for apprising other departments of internal and external claim related issues that may impact the organization and take appropriate action to incorporate changes into the day-to-day operations.
  • Improves processes to increase department efficiency and assist with high-level resolution of non-routine customer inquiries and complaints for all customers.
  • Responsible for developing, maintaining and updating maintaining processes and procedures (i.e. Standard Operating Procedures (SOPs), Desk Top Procedures (DTPs), training manuals, and other operational procedures and tools.
  • Responsible for oversight, management, development, implementation, and communication of department programs.
  • Develop annual department budgets. Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
  • Coordinate business activities by maintaining collaborative partnerships with key departments.
  • Performs other duties as assigned.
Candidate Education:
  • Required: Bachelor's Degree in Nursing; or equivalent work experience
Candidate Experience:
  • Required: 5 years of experience in health insurance operations
  • Required: 2 years of experience supervising or managing others
  • Required 2 years of experience in nursing
Candidate Skills:
  • Ability to drive multiple projects
  • Ability to effectively present information and respond to questions from peers and management
  • Ability to implement process improvements
  • Ability to work in a fast paced environment with changing priorities
  • Ability to lead/manage others
  • Demonstrated interpersonal/verbal communication skills
  • Demonstrated written communication skills
  • Knowledge of medical terminology and/or experience with CPT and ICD-10 coding
  • Knowledge of healthcare delivery
  • Industry standards related to payment rules and methods
  • Milliman or InterQual guidelines
Licenses and Certifications:
A license in one of the following is required:
  • Required: Registered Nurse (RN)
Technical Skills:
  • Required: Microsoft Excel
  • Required: Microsoft Outlook
  • Required: Microsoft Word
  • Required: Microsoft PowerPoint
  • Required: Healthcare Management Systems

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Last Updated On: 12/9/2015