HC-0218 Case Manager-Quality Review -- New York, NY

We are on a retained search with a major Healthcare oranization in New
York, NY. Below is the PERMANENT position being offered. If available
and interested, please send current resume and current salary or rate.
Thank you.
 
 
Job Title:        HC-0218 Case Manager - Quality Review
Location:        New York, NY
Duration:        Permanent-Full Time
Rate:              $50,000-$60,000 /yr
 
 
Job Description
The responsibilities of this position include:
 
Reviewing pertinent clinical information/medical records utilizing the
appropriate clinical protocols to support appeals and retrospective
reviews. Supporting the external appeal process for the company and
its vendors by collaborating with them. Entering case documentation in
Max Mc and generating notifications of determinations in accordance
with state, federal and accrediting body standards.
 
Contacting members and/or providers to obtain additional clinical
information as needed to render utilization review determinations.
Confers with internal and external Medical  Consultants on
retrospective reviews, internal and external appeals.
 
Reviews/reconciles Daily Claims Exception Report. Renders
precertification penalty determinations. Maintains database on
retrospective reviews and appeals. Assists with compiling the Schedule
M Report.
 
 
Requirements
The qualifications for this position are:
· Current license to practice nursing in New York State
· Minimum of 2 years acute Medical/Surgical experience 
· Baccalaureate Degree in Nursing preferred
· Knowledge of claims preferred
· Excellent oral and written communication skills required
· Excellent organizational skills required
· Ability to multi-task
· Computer proficiency required (Word,Excel)
· Familiarity with Managed Care Law, Department of Labor Law and URAC
UM Standards preferred
 
The work week is Monday through Friday, 9:00 a.m. to 5:00 p.m.
 
Regards,
 
Marlene Viegas-RN,C
The Barron/Carlington Group
Email: [email protected]
URL:   www.barronsys.com