Medical Policy Supervisor
3 weeks ago
Job Summary
The Medical Review Supervisor at CommunityCare is responsible for overseeing the day-to-day operations of our medical claim review program. This includes guiding individuals in implementing auditing and monitoring functions to identify areas of risk and potential fraud, waste, and abuse related to provider billing practices.
Key Responsibilities
- Provides technical expertise to Medical Review staff, including analysis, problem-solving, and decision-making of complex claim reviews.
- Identifies medical necessity and/or quality issues for further evaluation.
- Oversees the triage of pended and high-dollar claims.
- Works collaboratively with other departments to provide or seek claims review and/or clinical guidance.
- Proactively conducts routine monitoring and identifies areas of potential fraud, waste, and/or abuse.
- Coordinates and/or oversees daily activities of the MRE staff, including planning, implementing, and evaluating MRE goals.
- Develops and implements operational guidelines for applicable payment policies and/or for other processes pertaining to the medical claim review function.
- Monitors the medical claim review tracking database for quality control.
- Compiles and analyzes data and prepares routine compliance reports.
Requirements
- Highly organized and capable of managing multiple projects.
- Proficient in Microsoft applications.
- Minimum of five years combined employment in facility/provider healthcare settings or managed care organization.
- Prefer strong clinical-related background and case review experience focused in healthcare fraud, waste, and abuse.
- Require experience or familiarity with state and federal regulations governing healthcare coding, billing, and claims processing.
CommunityCare is an equal opportunity employer
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