Care Management Coordinator, Medical Review - Remote (PA/NJ/DE)
Our organization is looking for dynamic individuals who love to learn, thrive on innovation, and are open to exploring new ways to achieve our goals. If this describes you, we want to speak with you. You can help us achieve our vision to lead nationally in innovating equitable whole-person health.
The Care Management Coordinator, Medical Review conducts post service reviews on medical claims and cases to ensure medical criteria has been met in accordance with current Company medical policies and medical management guidelines for inpatient, outpatient, surgical and diagnostic procedures including out of network services.
Responsibilities/Duties
· Reviews provider submission of medical records for specific services that have been processed through system automation and require documentation to determine if additional payment is warranted.
· Reviews specific medical services during the claims adjudication process against medical policies and medical management guidelines to ensure criteria has been met and provides direction to claims processing area.
· Conducts analysis review of post payment claims against current medical policy and medical management guidelines
· Identifies claims/services that require medical records review retrospectively
· Works with Hospitals and Professional providers to obtain medical records to conduct retrospective reviews
· Reviews medical records for identified claims/services to ensure medical criteria based on policies and guidelines have been met
· Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Directors for further evaluation determination
· Collaborates with appropriate areas of the Company including Care Management, Medical Policy, CFID, Appeals, Clinical Vendor Management and Claims Operations.
· Summarizes and tracks all analyses performed and reports to Management
· Identifies and suggests process improvements or potential process efficiencies based on reviews conducted
· Participates in key business area projects
· Assists with review and maintenance of the Claim Medical Review team’s policies, procedures, checklists and documentation as required.
· Performs other related duties as assigned
Knowledge/Skills/Qualifications
· RN license, BSN Preferred
· Minimum 3-5 years' experience with medical criteria reviews
· Strong knowledge of ICD-10, HCPCS and CPT coding/billing
· Claims auditing experience a plus
· Proficiency with Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs. Ability to learn new systems as technology advances.
· Self motivated, highly organized and detailed oriented as well as problem solving, analytical, verbal and written communication skills are required
· Demonstrate the ability to work in a multi-tasking environment
Fully Remote:
This role is designated by Independence as fully remote. The incumbent will not be required to report to one of Independence’s physical office locations to perform the work. However, the work must be performed in the Tri-State Area of Delaware, New Jersey, or Pennsylvania.
IBX is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Must have an Android or iOS device which is compatible with the free Microsoft Authenticator app.
Vaccination Update
This job requires that you demonstrate you have been fully vaccinated for COVID-19 prior to the start of employment, to the extent permitted by law.
About Our Company
AmeriHealth Casualty has been successfully returning employees to work since 1994, providing quality medical treatment and care and reducing costs for our customers. With our affiliates, we serve more than 1,800 businesses in the area and have offices in Philadelphia, Camp Hill, and Pittsburgh, PA, and Mount Laurel, NJ.
In 1994, CompServices, Inc. began offering workers’ compensation third-party administration services for manufacturers, municipalities, health care facilities, social services, transportation risk, universities, and retail firms. In 1996, AmeriHealth Casualty Insurance Company was established as an extension of our workers’ compensation claims services — its mission to provide workers’ compensation insurance combined with high quality claims service and cost containment.
AmeriHealth Casualty Insurance Company and CompServices write premiums and administer self-insured programs for over 1,800 customers.
Equal Employment Opportunity
AmeriHealth Casualty is an Equal Opportunity and Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to their age, race, color, religion, sex, national origin, sexual orientation, protected veteran status, or disability.
Agency Disclaimer
All resumes submitted directly to an AmeriHealth Casualty employee from a vendor via email, the Internet or in any other form without a valid written search agreement in place for this position from the Independence Blue Cross Family of Companies Human Resources Department will be deemed the sole property of AmeriHealth Casualty and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by AmeriHealth Casualty or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.