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

Bachelor's degree in a job-related field
5 years clinical and utilization review to include 2 years 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
Ability to persuade, negotiate or influence, and handle confidential or sensitive information with discretion
Knowledge of government programs and guidelines, medical and legal terminology, and disease management and litigation processes
Active RN licensure in state hired, OR, active compact multistate RN license as defined by the Nurse Licensure Compact (NLC)

Manager, Medical Review – Medicare Appeals, Utilization Review, Part A, HHH

Key skills