A rewarding, challenging leadership opportunity that allows work/life balance? You may call it unlikely, we call it MJHS! The Manager of Review Operations develops and implements departmental initiatives and oversees retrospective medical record reviews, both on-site and in provider settings. The manager also oversees the categorizing and recording of each document associated with retrospective reviews in the appropriate system(s). In addition, he or she will manage in-house staff, vendors and vendor contracts for retrospective review process while ensuring 95% or greater of appropriate determinations and recommendations for members based on established criteria including CAF/PRI compatibility, CM recommendations, and NHC recommendations.
Ideal candidate will have a bachelors degree in a health related field and 3-5
years managed care experience in utilization review, quality management, and/or
medical necessity/coding review. Minimum of 1-2 years supervisory experience required as well.
Must be proficient in Windows, Word and Excel and an RN with New York State licensure.
Knowledge of physician and facility billing/reimbursement methodologies. Some knowledge of claims payment
processes. Working knowledge of utilization management processes. Familiarity
with Interqual criteria for assessment of medical necessity of services a must.