Medical Management - Supervisor Medical Review 145-4005

The Medical Review Supervisor is responsible for overseeing activities and personnel involved in the day to day operations of CommunityCare’s medical claim review program. The Supervisor guides individuals in implementing auditing and monitoring functions aimed at identifying areas of risk and/or potential fraud, waste and abuse, as it relates to provider billing practices.

Provides technical expertise to Medical Review (MRE) staff including analysis, problem solving, and decision making of complex claim reviews. Identifies medical necessity and /or quality issues for further evaluation. Oversees triage of pended and high dollar claims. Collaborates with external vendors on cases meeting reinsurance thresholds and specific requirements for ASO lines of business. Works collaboratively with other departments in providing or seeking claims review and/or clinical guidance. Participates in company committees or work groups as assigned. Proactively conducts routine monitoring and identifies areas of potential fraud, waste and/or abuse (FWA). Formulates recommendations based on findings. Suggests opportunities for focused reviews. Works collaboratively with the Compliance Officer and/or Special Investigations (SIU) as needed. Coordinates and/or oversees daily activities of the MRE staff. This includes planning, implementing and evaluating MRE goals. It also includes monitoring workload, staff supervision, training, coaching, auditing, teambuilding, performance evaluation and hiring/retaining staff. Provides training for new MRE staff including one-to-one sessions as required for successful staff mastery of job tasks related to claim reviews and special projects. Develops and implements operational guidelines for applicable payment policies and/or for other processes pertaining to the medical claim review function. Seeks organizational approval as indicated. Monitors the medical claim review tracking database for quality control. Compiles and analyzes data and prepares routine compliance reports. Performs other duties as required.