Hybrid RN Medical Review Manager

at Palmetto GBA

• Job title: RN Medical Review Manager
• Job type: Full Time
• Experience level: Mid level, Senior
• Salary: Not specified
• Degree requirement: Bachelor's Degree
• Location requirements: Hybrid, United States

About the role

• Medical Review Manager overseeing accurate processing of medical necessity claims for Palmetto GBA subsidiaries. Ensure compliance, manage teams, and implement process improvements.

Responsibilities

• Oversees the accurate processing of claims that have been deferred for medical necessity review.
• Ensures compliance with nationally recognized standards, and local, state, and federal laws and regulations.
• Identifies and implements process improvement opportunities.
• Manages the medical review process.
• Maintains a well-trained staff.
• Develops/implements medical review strategy with the ultimate goal of reducing the error rate.
• Ensures timeliness of review, quality of decisions, set productivity levels, and compliance with all nationally recognized standards, and local/state/federal laws and regulations.
• Identifies missed standards and implements corrective actions.
• Provides comprehensive and accurate feedback to provider community regarding results of medical review and correction action.
• Investigates all internal and external inquiries and ensures they are responded to in a timely and accurate manner.
• Interfaces with internal and external customers such as appellants/attorneys, congressional offices, and other regulatory bodies as required to build and maintain positive customer relationships.

Requirements

• Bachelors Degree in Nursing
• Five years of clinical and utilization review to include two years of supervisory or team lead experience or equivalent military experience in grade E4 or above.
• Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills.
• Good judgment skills.
• Proficient spelling, grammar, punctuation, and basic business math.
• Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC).

Benefits

• Excellent verbal and written communication, organizational, customer service, analytical or critical thinking, and presentation skills.
• Good judgment skills.
• Proficient spelling, grammar, punctuation, and basic business math.
• Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion.