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Manager, Medical Review Unit

Smyrna, Georgia Apply Now Job ID 1152764 Category Leadership Organization Peach State Health Plan Schedule Full-time

Position Purpose: Manage the review of medical claims for billing coding and other compliance or reimbursement related issues, assist with non clinical aspects of the medical review and project management functions such as gathering information.

  • Manage the work flow of the medical review unit and assist with policy and procedure development and train staff.
  • Develop, implement and maintain production and quality standards for the medical review unit staff.
  • Oversight of standalone office location including daily personnel issues, supplies, staffing, and safety.
  • Investigate medical claims, records and other requested information for billing, coding, and other compliance or reimbursement related issues and make payment.
  • Receive and respond to inquiries and issues from the Claims Department regarding code review and appeals.
  • Maintain departmental database, correspondence and files.
  • Assess and categorize new Physician’s Current Procedural Terminology (CPT), International Classification of Diseases (ICD) coding, government (HCPC) and home grown codes for information system configuration annually.

  • Qualifications:

    Education/Experience: Nursing degree and state registered nursing license with an advanced degree preferred. 3+ years nursing experience and 3–5 years of quality improvement and management experience in a healthcare environment, preferably managed care. Thorough knowledge of Physician’s Current Procedural Terminology (CPT) and International Classification of Diseases, 9th Edition (ICD-9). Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.

    License/Certification: RN license.

    Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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