Medical Claims Review Manager jobs in California

Medical Claims Review Manager oversees the performance, productivity, and quality of the medical claims review staff. Responsible for hiring, training, and firing medical claims review staff. Being a Medical Claims Review Manager evaluates medical claims review processes and recommends process improvements. Serves as a technical resource for all medical review workers. Additionally, Medical Claims Review Manager typically requires an RN or BSN. Requires a bachelor's degree. Typically reports to a head of a unit/department. The Medical Claims Review Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. Extensive knowledge of department processes. To be a Medical Claims Review Manager typically requires 5 years experience in the related area as an individual contributor. 1 to 3 years supervisory experience may be required. (Copyright 2024 Salary.com)

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Medical Claims Review Nurse - Full Remote
  • Morgan Stephens
  • Long Beach, CA FULL_TIME
  • Position Title: Medical Claims Review Nurse

    Type: Fully Remote

    Schedule: Monday to Friday, 9:00 AM to 5:00 PM PST/PDT

    Candidates must live in Pacific Time Zone

    Daily Responsibilities

    • Reviewing medical patient records against standard medical criteria.

    Minimum Qualifications

    • Three years of clinical appeals experience.
    • One year of utilization review experience.
    • Candidates with DRG experience on their resume will be prioritized for interviews.

    Job Summary

    • Perform clinical/medical reviews of retrospective medical claim reviews, medical claims, and previously denied cases.
    • Ensure medical necessity and appropriate/accurate billing and claims processing.
    • Identify and report quality of care issues.
    • Refer members with special needs to appropriate healthcare organization programs.
    • Assist with complex claim review requiring decision-making based on clinical experience.
    • Document clinical review summaries, bill audit findings, and audit details in the database.
    • Provide supporting documentation for denial and modification of payment decisions.
    • Re-evaluate medical claims independently by applying advanced clinical knowledge and relevant regulatory requirements.
    • Review clinical guidelines with Medical Directors on denial decisions.
    • Serve as a clinical resource for various stakeholders.
    • Provide training, leadership, and mentoring.
    • Resolve escalated complaints regarding utilization management and long-term services and supports.
    • Prepare and present cases for various hearings as required.

    Job Function

    • Administer claims payments, maintain claim records, and provide counsel to claimants.
    • Monitor and control backlog and workflow of claims.
    • Ensure timely settlement of claims in accordance with cost control standards.

    Required Education

    • BSN Preferred.

    Required Experience

    • Minimum three years of clinical appeals review experience.
    • Minimum one year of utilization review.

    Required License, Certification, Association

    • Active, unrestricted State Registered Nursing (RN) license in good standing.
    • LPN/LVN Considered based on experience

    Compensation and Benefits:

    • $90,000 and up plus full benefit package
  • 8 Days Ago

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Medical Claims Review Specialist -MCRS24-04472 - 1 BIZ
  • Navitas Partners Careers (North America)
  • Los Angeles, CA FULL_TIME
  • Position: Medical Claims Review SpecialistLocation: 10920 Wilshire Blvd, Los Angeles, CA 90024Duration: 24 week contractSHIFT: M-F 8-5 Note: This position is 99% remote, with only the orientation and ...
  • 12 Days Ago

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Medical Assistant
  • Home Health Account Manager
  • Oakland, CA FULL_TIME
  • Job Title: Medical Assistant Location: Oakland Employment Type: Full-time, candidates must have authorization to work in the United States; visa support is not provided. Salary: $19-22 per hour Benefi...
  • 16 Days Ago

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Senior Manager, Medical Information, and Review
  • Acadia Pharmaceuticals Inc.
  • San Diego, CA FULL_TIME
  • This position will serve as an integral member of Medical information (MI) and Medical Review (MLR/MRC) teams responsible for medical accuracy review as part of the Promotional Review Committee and Me...
  • 9 Days Ago

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Workers Compensation Claims Associate | Medical Only | Orange, CA (In-Office)
  • Sedgwick Claims Management Services Inc.
  • Orange, CA FULL_TIME
  • Taking care of people is at the heart of everything we do, and we start by taking care of you, our valued colleague. A career at Sedgwick means experiencing our culture of caring. It means having flex...
  • 10 Days Ago

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Claims Manager - Medical Facilities
  • Ultimate
  • Diamond, CA FULL_TIME
  • Job Description We are looking for a Claims Manager to join an established company!On-site in Diamond Bar, CA$85k-$100k AnnuallyKEY DUTIES AND RESPONSIBILITIES:* Provide an environment that allows sta...
  • 5 Days Ago

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Hospital Medical Leader
  • Petco
  • Folsom, CA
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 6/10/2024 12:00:00 AM

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Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Alameda, CA
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 6/9/2024 12:00:00 AM

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Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Fairfield, CA
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 6/9/2024 12:00:00 AM

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Head of Medical Writing
  • Barrington James
  • Clinical-stage biopharmaceutical company in San Francisco, is seeking a Head of Medical Writing. This leadership role in...
  • 6/8/2024 12:00:00 AM

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Head of Medical Strategy
  • ExecuSearch
  • Atlanta, GA
  • The Head of Medical Strategy provides medical expertise to the rheumatology commercial and medical teams and provides cl...
  • 6/8/2024 12:00:00 AM

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Head of Medical Strategy Rheumatology
  • UCB
  • Atlanta, GA
  • Make your mark for patients The Head of Medical Strategy provides medical expertise to the rheumatology commercial and m...
  • 6/8/2024 12:00:00 AM

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Hospital Medical Leader
  • Petco Animal Supplies Inc
  • Pinellas Park, FL
  • Create a healthier, brighter future for pets, pet parents and people! If you want to make a real difference, create an e...
  • 6/8/2024 12:00:00 AM

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Head of Medical Writing
  • Barrington James
  • San Francisco, CA
  • Head of Medical Writing - Rare disease Biotech We are currently partnered with a growing, west coast based biotech focus...
  • 6/7/2024 12:00:00 AM

California is a state in the Pacific Region of the United States. With 39.6 million residents, California is the most populous U.S. state and the third-largest by area. The state capital is Sacramento. The Greater Los Angeles Area and the San Francisco Bay Area are the nation's second and fifth most populous urban regions, with 18.7 million and 9.7 million residents respectively. Los Angeles is California's most populous city, and the country's second most populous, after New York City. California also has the nation's most populous county, Los Angeles County, and its largest county by area, S...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Medical Claims Review Manager jobs
$108,120 to $137,855

Medical Claims Review Manager in Parkersburg, WV
This end-to-end e-billing and e-payment solution is fully integrated with DecisionPoint, which means it can be immediately and easily integrated with your providers, adjusters, IT infrastructure, and claims workflow—enabling you to.
January 01, 2020
Medical Claims Review Manager in Juneau, AK
Examples include a claims examiner’s view of a particular bill’s status in a claim record’s related bill screen, or a bill review analyst’s view of an available reserve amount for the claim record related to the bill they are processing.
December 03, 2019
Medical Claims Review Manager in Galveston, TX
Assists the Manager, Medical Review with performing duties to oversee day-to-day activities within the Medical Claims Review Department to facilitate the achievement of business goals and targets.
December 16, 2019