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.
Inclusion and Belonging
At IBX, everyone can feel valued, supported, and comfortable to be themselves, and all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. Celebrating and embracing diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.
About Our Company
Serving more than 8 million people nationwide, including 2.5 million in southeastern Pennsylvania, Independence Health Group — together with its subsidiaries — is the leading health insurance organization in the Philadelphia region. Our mission to build healthier lives for you, your family, and your employees shapes our actions and decisions every day.
At Independence, we see each of our members as an individual, with unique needs and concerns. We’re dedicated to harnessing the very latest ideas and technologies to deliver access to care that meets those needs and surpasses your expectations. For more information about Independence access our website at www.ibx.com. We’re revolutionizing health care, and our focus is on you!
Equal Employment Opportunity
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.
Agency Disclaimer
All resumes submitted directly to an Independence Blue Cross 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 Independence Blue Cross and the Independence Blue Cross Family of Companies. Please note that no fee will be paid in the event the candidate is hired by Independence Blue Cross or the Independence Blue Cross Family of Companies as a result of the referral or through means other than our established process.