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Medical Review Manager

NE - Omaha

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Opportunity Snapshot

Fight Medicaid fraud and abuse at the national level as you enable the recovery of millions of dollars back to the federal government!

In this role, you will enjoy the "best of both worlds": the clinical sophistication of IntegriGuard, a recognized leader in program integrity, and the resources and career opportunities of Health Management Services (HMS), our parent corporation that ranked #3 on Fortune's 2009 FSB 100 list of America's fastest growing small public companies.

This is a hands-on leadership opportunity to leverage your medical review expertise and guide your team of ten Medical Review nurses and Quality staff to work smarter as you spark them to achieve their own best potential.
Quick question for you - click here

The Medicare environment is very complex with a profusion of rules and regulations and pivotal to your success in this role is self-initiative and problem solving savvy; Our medical reviews can range from a simple physician claim to a complex hospital or nursing facility claim with a voluminous medical record, but you'll take ownership of whatever comes your way and stay on top of tight deadlines to ensure we meet the contract deliverables.

IntegriGuard, now a wholly-owned subsidiary of HMS, is an ISO-certified and URAC-accredited organization devoted to the prevention and detection of fraud, waste, and abuse in the healthcare system. The driving force behind our success is our employees - knowledgeable, innovative, and results-oriented professionals who provide unparalleled customer service.

What You'll Bring to the Table

A Bachelor's degree in Nursing, Business or related field.
An active RN license with 5+ years of nursing experience, including at least one year of medical review background. Quick question for you - click here
3+ years of leadership experience in the area of medical/utilization review.
Deep knowledge of the Medicare program, particularly the medical record review, billing and reimbursement rules.Quick question for you - click here
Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.
Strong Project management skills.
Excellent interpersonal and communication skills.
Computer proficiency with Microsoft office suite, including Word, Excel & PowerPoint.
Outstanding organizational skills and the ability to maintain high quality work while meeting strict deadlines.
A self-starter approach and demonstrated ability to achieve goals independently.

Preferred but not required:

Medical coding experience.
Broad range of Federal / State / Private clinical experience, including Medicare and Medicaid.
Provider billing and/or reimbursement experience.

What's in It for You

Million-dollar impact -- this program will take advantage of IntegriGuard's portfolio of best practices, systems and resources, and will be in operational mode as you come on board. At the same time, you will be able to influence the ongoing growth of this program, including coaching and developing your team as well as refining processes.
Clinical sophistication through continuous improvement -- our URAC accreditation requires that we maintain continuous organizational improvement processes, and we never stop learning and growing. This spirit has enabled us to achieve industry recognition for our expertise. In fact, we are designated by the Centers for Medicare and Medicaid Services (CMS) as one of eight Qualified Independent Contractors (QIC) in the US, meaning CMS acknowledges that we have the expertise and capabilities to perform appeals of Medicare claims between the carrier and Administrative Law Judge levels.
Career advancement -- we're hiring now with an eye on the future, looking for impact players who can grow with us. You will be well positioned to evolve your career along multiple directions, depending on your ambition and aptitude.
A culture of growth and transition -- we are positioned for explosive growth both organically and via acquisition. At the same time, we are proactive about maintaining a culture in which employee input is welcome, initiative is encouraged, and excellence and innovation are highly valued.

Excellent compensation -- in addition to a competitive, we offer a comprehensive benefits package that includes a 401(k) plan, flexible spending plans, free parking and much more.

Role Specifics

At a high level, you'll spend about one third of your time on production; another one third on managing staff; and the remaining one third on quality issues as you aim to drive process improvements. Specifically, your responsibilities will be to:

Provide daily guidance and training to medical review staff, including oversight of workload assignments given to medical review nurses.
Manage workload of the Medical Review department to ensure that adequate resources are allocated, and contract timelines and budget are achieved.
Oversee determinations in order to ensure the consistency of decision-making by medical review nurses.
Ensure all project deliverables are met in the required timeframes.
Collaborate with Medical Review management team to develop and revise work instructions and address identified training needs of Medical Review division.
Maintain relationships with CMS, OIG, and the Affiliated Contractor, prime or subcontractors, including regular participation in conference calls.
Participate in and contribute to the quality management system.

Keys to Success

Outstanding leadership skills are perhaps the most critical success factor for this role. You will be working with a team of ten Medical Review Nurses to perform pre-payment and post payment medical reviews of claims submitted by Medicare providers. You will provide daily oversight of the assigned medical review contract operations and training to medical review staff, and oversight of the process to review determinations by nurses. You will also collaborate with the Medical Director regarding determinations, quality monitoring, and training, and well as preparing reports and deliverables. In addition, we'll look to you to keep an eye out for opportunities to expand the current contract or provide services in other areas.

Second to being a great leader, you'll need to be passionate about our mission. Our bottom line goal is reducing fraud, waste, or abuse, and our most successful - and happiest - managers share in that passion and bring a high level of energy to reaching our targets.

Who We Are

IntegriGuard, LLC is an ISO-certified and URAC-accredited organization devoted to the prevention and detection of fraud, waste, and abuse in federal healthcare systems. IntegriGuard offers a suite of program integrity and payment accuracy solutions designed to detect fraud and improper payments. The company's services include audit, compliance & education, data & analysis, eligibility verification, medical review, and investigation. In addition to being designated by the Centers for Medicare & Medicaid Services (CMS) as one of 12 Program Safeguard Contractors, and one of eight Medicare Prescription Drug Integrity Contractors, IntegriGuard is one of eight Qualified Independent Contractors for CMS.