The Medical Review Manager supports the Centers for Medicare and Medicaid Services (CMS) by managing the Medical Review task under the Payment Error Rate Measurement (PERM) contract. This position ensures that the nurses and coders who perform medical reviews have all needed knowledge and tools to successfully perform the required duties. Additionally, the Medical Review Manager performs quality checks of the medical review team findings. This position works collaboratively with all related Task Leaders and supports team efforts to ensure high quality standards and results are achieved.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Essential duties and responsibilities include the following. Other duties may be assigned.
Responsible for the integration of CNI Core Competencies into daily functions, including: commitment to integrity, knowledge / quality of work, supporting financial goals of the company, initiative / motivation, cooperation / relationships, problem analysis / discretion, accomplishing goals through organization, positive oral / written communication skills, leadership abilities, commitment to Affirmative Action, reliability / dependability, flexibility and ownership / accountability of actions taken.
Directs, trains, supervises and manages the PERM Medical Reviewers. Ensures quality, consistency and timeliness of all reviews.
Manages the scope of work for all assigned State PERM medical reviews. Ensures that milestones are completed on time.
Works collaboratively with the policy team to assure appropriately collected state and federal policies needed for the Medicaid and Children’s Health Insurance Program (CHIP) review are processed correctly and available to the reviewers.
Works collaboratively with the policy team to research and track new regulations relevant to PERM.
Participates in orientation calls with States under review to confirm located policies. Seeks clarifications, identifies missing manuals / policies, and explains the medical review process.
Maintains training materials related to medical reviews.
Keeps Assistant Project Director for Medical Review informed of medical review status. Serves as a liaison between reviewers and other Task Leaders.
Responsible for aiding in own self-development by being available and receptive to all training made available by the company.
Plans daily activities within the guidelines of company policy, job description and supervisor’s instruction in such a way as to maximize personal output.
Responsible for keeping own immediate work area in a neat and orderly condition to ensure safety of self and coworkers. Will report any unsafe conditions and/or practices to the appropriate supervisor and human resources. Will immediately correct any unsafe conditions to the best of own ability.
EDUCATION / EXPERIENCE
Bachelor's degree and a minimum of six (6) years relevant experience, or equivalent combination of education / experience, which includes three (3) years in practice as a licensed, Registered Nurse and three (3) years of supervisory management experience in the health insurance industry, a utilization review firm, or another healthcare claims processing organization that involves medical and coding reviews of a variety of medical and surgical claims from various provider types.
CERTIFICATES / LICENSES / REGISTRATION
Current Registered Nurse Licensure
U.S. Citizens / Green Card due to government or federal requirement
JOB SPECIFIC KNOWLEDGE / SKILLS / ABILITIES
Working knowledge of the Medicaid and/or CHIP program, related coverage and payment rules, and standardized coding review criteria
Operational knowledge of computers with skilled proficiency in the use of Microsoft Office Suite and the ability to quickly grasp customized software systems
Excellent supervisory skills with ability to effectively lead, mentor and train others
Solid organizational and leadership skills relevant to carrying out day-to-day responsibilities
Ability to manage multiple projects and priorities and to meet specified deadlines
Proficient in verbal, written and listening skills
Excellent customer service and relationship-building skills
Ability to interact and communicate with all levels of staff and management
Ability to effectively work both independently and in a team environment
Ability to read, analyze, and interpret the most complex documents. Ability to respond effectively to the most sensitive inquiries or complaints. Ability to write speeches and articles using original or innovative techniques or style. Ability to make effective and persuasive speeches and presentations on controversial or complex topics to top management, public groups, and or boards of directors.
Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.