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Manager of Review Operations

MJHS Type Full time Posted 4/25/2014
Salary - n/a - Starts 7/21/2014
NY - New York (All) - Brooklyn Referral - n/a -    
  We believe that nurses give their best care when they know they are being cared for too. When you work for MJHS, you’ll be valued and respected for your dedication to world-class patient care. You’ll be encouraged and challenged to learn and grow. Most of all, you’ll be rewarded with work/life programs that help you balance your priorities and enjoy the career you’ve always wanted. You won’t find that everywhere. But you will find it here.  

Manager of Review Operations

Req #: 105460
Agency: Elderplan
Job Locations: US-NY-Brooklyn

Status: Regular Full-Time
Category: Management
Office or Field: Office-based
The challenges of affordable healthcare continue to create new opportunities. Elderplan and HomeFirst, our Medicare and Medicaid managed care health plans, are outstanding examples of how we are expanding services in response to our patients' and members' needs. These high-quality healthcare plans are designed to help keep people independent and living life on their own terms.


We truly value our staff and further acknowledge their contributions by offering:

  • Employee and family health coverage
  • Competitive salaries
  • Employer contributed pension plan
  • Generous time off
  • Tuition reimbursement
  • 403(b) retirement plan
Develops and implements departmental initiatives and oversees retrospective medical record reviews, both on-site and in provider settings. Oversee the categorizing and recording of each document associated with retrospective reviews in the appropriate system(s). Manages in-house staff, vendors and vendor contracts for retrospective review process. Ensures 95% or greater of appropriate determinations and recommendations for members based on established criteria including CAF/PRI compatibility, CM recommendations, and NHC recommendations. Implements, monitors, and evaluates NHC process. Trains and acts as a resource to all staff and makes recommendations for changes in policy, procedures, and workflows as deemed appropriate.
Bachelor's degree in a health related field preferred. 3 5 years managed care experience in utilization review, quality management, and/or medical necessity/coding review. Two years of supervisory experience. Minimum of 1 2 years supervisory experience. Proficient in Windows, Word and Excel. One or more of the following credentials: RN, LPN, Credential as RHIA, RHIT, CCS, or CCS-P. Knowledge of physician and facility billing/reimbursement methodologies. Some knowledge of claims payment processes. Working knowledge of utilization management processes. Familiarity with Interqual criteria for assessment of medical necessity of services. Knowledge of State and Federal regulations. Knowledge of CQI methodologies.

We are an equal opportunity employer M/F/D/V.