caregiver in surprise | pto — still get paid on your days off

care manager (rn)

clinical appeals nurse

medical review nurse analyst Jobs in Michigan

medical review nurse analyst

medicare advantage rn review analyst

Strategic Staffing Solutions

<div>
 
 
 
 Medicare Advantage RN Review Analyst
 
 
 
 
 
 Location:
 
 Detroit, MI
 
 (Remote however must be local to Michigan)
 
 
 
 
 Duration:
 
 12+ Months with opportunity for FTE
 
 
 
 Role Type:
 
 W2 Contract role
 
 
 
 Max Pay Rate:
 
 $36/HR
 
 
 
 Schedule:
 
 Monday - Friday 9-5
 
 
 
 
 
 
 SUMMARY
 
 
 
 Responsible for the approval or rejection of claims and/or benefit interpretation. May be required to enter or reference data via PC and/or Clinical Review Team terminal.
 
 
 
 
 
 
 REQUIREMENTS
 
 
 <ul>
 <li>
 Registered Nurse with current Michigan Registered Nurse License.
 </li>
 <li>
 Associate degree or nursing diploma required, bachelor&rsquo;s degree preferred.
 </li>
 <li>
 Two (2) years RN patient care experience.
 </li>
 <li>
 Triage, case management and/or rehabilitation experience preferred.
 </li>
 <li>
 Medicare Advantage Part B experience a plus.
 </li>
 <li>
 Expertise in the use of medical terminology.
 </li>
 <li>
 Finely honed critical thinking skills are a must.
 </li>
 <li>
 Knowledge of CPT/HCPCS coding and Medicare regulations desirable.
 </li>
 </ul>
 
 
 
 
 
 CERTIFICATES, LICENSES, REGISTRATIONS
 
 
 <ul>
 <li>
 Current unrestricted state of Michigan registered nurse license required.
 </li>
 </ul>
</div>

Medicare Advantage RN Review Analyst

WPS—A health solutions company

<div>
 Our
 
 Medical Review Nurse Analyst
 
 is responsible for conducting clinical reviews of medical records to ensure compliance with regulatory and payer guidelines. This analyst ensures that providers are being reimbursed appropriately for services provided based on Medicare guidelines. This
 
 Medical Review Nurse Analyst
 
 reviews claims and delivers provider education on current billing and documentation requirements.
 
 
 
 Salary Range
 
 
 
 
 $68,000 - $70,000
 
 
 
 
 The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.
 
 
 
 
 Remote Work Location
 
 
 
 
 We are open to remote work in the following approved states:
 
 
 
 Colorado, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, New Jersey, North Carolina, Ohio, South Carolina, Texas, Virginia, Wisconsin
 
 
 
 How do I know this opportunity is right for me? If you:
 
 
 
 <ul>
 <li>
 Can perform detailed reviews of medical records and documentation to determine the medical necessity of services.
 </li>
 <li>
 Would enjoy reviewing submitted claims to ensure that billed services are medically necessary and correctly coded based on Medicare guidelines.
 </li>
 <li>
 Want to ensure Medicare providers are correctly reimbursed when documentation supports services rendered.
 </li>
 <li>
 Have prepared written clinical summaries and determinations with clear rationale for approvals, denials, or modifications.
 </li>
 <li>
 Would like to educate providers in accordance with the Targeted Probe and Educate (TPE) program.
 </li>
 <li>
 Can monitor the progress of assigned providers and educate on current billing and documentation requirements.
 </li>
 <li>
 Want to ensure compliance with federal and state regulations, CMS guidelines, and company policies.
 </li>
 <li>
 Enjoy staying current on clinical guidelines, medical policy updates, and industry best practices.
 
 
 </li>
 </ul>
 
 Minimum Qualifications
 
 
 
 <ul>
 <li>
 Associate&rsquo;s (ASN) or Bachelor&rsquo;s Degree in Nursing (BSN).
 </li>
 <li>
 Active RN license, applicable to state of practice in good standing.
 </li>
 <li>
 1 or more years of clinical experience in a healthcare setting (hospital, homecare, skilled nursing, etc.).
 </li>
 <li>
 Excellent written and verbal communication skills, with the ability to communicate complex medical information clearly and concisely.
 </li>
 <li>
 Strong attention to detail and organizational skills to manage multiple cases simultaneously.
 </li>
 <li>
 Basic knowledge and understanding of medical/clinical review processes.
 </li>
 <li>
 Solid computer skills with experience working in multiple on-line systems including MS Outlook, Teams, OneNote, Word, and Excel.
 
 
 </li>
 </ul>
 
 Preferred Qualifications
 
 
 
 <ul>
 <li>
 Experience working for a Medicare Administrative Contractor (MAC).
 </li>
 <li>
 Familiarity with Medicare guidelines and reimbursement processes.
 </li>
 <li>
 Experience with medical record review or utilization review.
 
 
 </li>
 </ul>
 
 Remote Work Requirements
 
 
 
 <ul>
 <li>
 Wired (ethernet cable) internet connection from your router to your computer
 </li>
 <li>
 High speed cable or fiber internet
 </li>
 <li>
 Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
 </li>
 <li>
 Please review Remote Worker FAQs for additional information
 
 
 </li>
 </ul>
 
 Benefits
 
 
 
 <ul>
 <li>
 Remote work options available
 </li>
 <li>
 Performance bonus and/or merit increase opportunities
 </li>
 <li>
 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
 </li>
 <li>
 Competitive paid time off
 </li>
 <li>
 Health insurance, dental insurance, and telehealth services start DAY 1
 </li>
 <li>
 Professional and Leadership Development Programs
 </li>
 <li>
 Review additional benefits: (https://www.wpshealthsolutions.com/careers/)
 
 
 </li>
 </ul>
 
 Who We Are
 
 
 
 WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.
 
 
 
 Culture Drives Our Success
 
 
 
 WPS&rsquo; culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce&mdash;both current and future&mdash;to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.
 
 
 We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.
 
 
 
 Sign up for
 
 
 Job Alerts
 
 
 
 
 FOLLOW US!
 
 
 
 
 Instagram
 
 
 
 
 LinkedIn
 
 
 
 
 Facebook
 
 
 
 
 WPS Health Blog
 
 
 
 This position supports services under Centers for Medicare &amp; Medicaid Services (CMS) contract(s). As such, the role is subject to all applicable federal regulations, CMS contract requirements, and WPS internal policies, including but not limited to standards for data security, privacy, confidentiality, and program integrity. CMS contractors and their personnel are subject to screening and background investigation including fingerprinting prior to being granted access to information systems and/or sensitive data to safeguard government resources that provide critical services
</div>

Medical Review Nurse Analyst

LanceSoft, Inc.

<div>
 
 
 Job Responsibilities:
 
 
 <ul>
 <li>
 The Care Manager RN leads the coordination of a multidisciplinary team to deliver a holistic, person centric care management program to a diverse health plan population with a variety of health and social needs.
 </li>
 <li>
 They serve as the single point of contact for members, caregivers, and providers using a variety of communication channels including phone calls, emails, text messages and the online messaging platform.
 </li>
 <li>
 The Care Manager RN uses the case management process to assess, develop, implement, monitor, and evaluate care plans designed to optimize the members health across the care continuum.
 </li>
 <li>
 They work in partnership with the member, providers of care and community resources to develop and implement the plan of care and achieve stated goals.
 </li>
 </ul>
 
 
 
 
 
 Education and Experience:
 
 
 <ul>
 <li>
 Nursing Diploma or Associates degree in nursing required.
 </li>
 <li>
 Bachelor&rsquo;s degree in nursing strongly preferred.
 </li>
 <li>
 3 years of clinical nursing experience in a clinical, acute/post-acute care, and community setting required.
 </li>
 <li>
 1 year of case management experience in a managed care setting strongly preferred.
 </li>
 <li>
 Experience managing patients telephonically and via digital channels (mobile applications and messaging) preferred.
 </li>
 <li>
 Current, active, and unrestricted Michigan Registered Nurse license required
 </li>
 <li>
 Certification in Case Management (CCM) required or to be obtained within 18 months of hire
 </li>
 <li>
 Certification in Chronic Care Professional (CCP) preferred
 </li>
 </ul>
</div>

Case Management Nurse

Munson Healthcare

<div>
 
 
 More Than Just Care, It&rsquo;s Community
 
 
 
 
 Imagine doing meaningful work in a place where people vacation. That&rsquo;s life at Munson Healthcare - northern Michigan&rsquo;s largest healthcare system, with eight award-winning community hospitals serving over half a million residents across 29 counties.
 
 
 If you want a career in healthcare and a lifestyle most people only dream about &ndash; with freshwater lakes, scenic trails, charming downtowns, a vibrant arts scene, and endless outdoor adventures - you might just be
 
 Munson Material.
 
 To us, that means teammates who live by our values of
 
 excellence, teamness, positivity, creativity,
 
 and a commitment to creating
 
 exceptional experiences
 
 for our patients and each other. Join a team that delivers outstanding care in one of the most beautiful regions in the country.
 
 
 
 
 Invested in You
 
 
 
 
 <ul>
 <li>
 Grow: Tuition reimbursement, in-person and online development, and access to our career hub to help you advance.
 </li>
 <li>
 Thrive: Full benefits, paid holidays, generous PTO, employee discounts, and free individual retirement counseling.
 </li>
 <li>
 Be Well: Free wellness platform for you and your family, plus personalized support for personal or family challenges.
 </li>
 <li>
 Be Heard: Share your ideas and help shape the way we work through improvement huddles, employee surveys, and town hall meetings
 
 
 </li>
 </ul>
 
 Job Description
 
 
 
 
 
 A Day In The Life
 
 
 
 
 <ul>
 <li>
 The Coder Abstractor is responsible for charge capture process for professional charges within the Munson system, including but not limited to: verifying and/or analyzing medical record and/or encounter form documentation to determine the principle and all secondary diagnoses and procedures; assigning diagnostic codes, procedural codes and modifiers using coding guidelines established by the Centers for Medicare and Medicaid Services (CMS) and Munson; performing data entry; and, performing discrepancy resolution.
 </li>
 <li>
 Serves as a liaison between CBO and sites/departments. Assists in the orientation and training of new employees within the coding and charge capture area.
 </li>
 <li>
 Responsible for reviewing office based electronic charges and encounter forms for completion and accuracy, including accuracy of ICD9/10CM, CPT and HCPCS modifier assignment. Codes and enters charges at a 95% accuracy rate.
 </li>
 <li>
 Reviews and interprets physician documentation of surgical procedures to accurately assign and enter billing codes. Identifies all applicable diagnosis procedures and codes. Codes and enters charges at a 95% accuracy rate.
 </li>
 <li>
 Works with central billing team to ensure charges are coded and entered within two business days.
 </li>
 <li>
 Identifies educational needs and/or compliance issues and reports them to the Director of Central Billing Office. Performs accurate data entry of charges.
 </li>
 <li>
 Responsible for resolving coding discrepancies related to coding and revenue capture. Responsible for obtaining and maintaining education appropriate to the position.
 </li>
 <li>
 Serves as an expert resource for physicians, office management staff and central billing staff. Researches and responds to coding and compliance questions, coordinates accurate assignment of procedure codes and modifiers.
 </li>
 <li>
 Performs other duties as assigned.
 
 
 </li>
 </ul>
 
 Qualifications
 
 
 
 
 
 What's Required
 
 
 
 
 <ul>
 <li>
 Associate&rsquo;s degree in Health Record Technology, or related healthcare field and two years of professional coding experience and must obtain the credentials of a Certified Professional Coder (CPC), Registered Health Information Administrator (RHIT), or Registered Health Information Administrator (RHIA) within 18 months of employment.
 </li>
 <li>
 OR three years of professional coding experience and has obtained the credentials of a certified professional coder (CPC), Registered Health Information Administrator (RHIT), or Registered Health Information Administrator (RHIA)
 </li>
 <li>
 OR four to five years of professional coding experience and must obtain the credentials of a certified professional coder (CPC) Registered Health Information Administrator (RHIT), or Registered Health Information Administrator (RHIA) within 18 months of employment
 
 
 </li>
 </ul>
 
 Additional Information
 
 
 
 
 Fully remote! Must have at least two years of general surgery coding.
 
 
 
 <ul>
 <li>
 Eligible for a sign-on bonus of $5,000*
 
 
 </li>
 </ul>
 
 
 Are you Munson Material? Apply today!
 
 
 
 
 Munson Healthcare requires all employees be vaccinated or have lab confirmed immunity for Measles, Mumps, Rubella and Varicella. MHC also requires all employees to receive a flu vaccine during the flu season in the year that they are hired and annually thereafter, or receive an approved medical or religious exemption.
</div>

Coder Abstractor - General Surgery - REMOTE

Meridian

<div>
 You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you&rsquo;ll have access to competitive benefits including a fresh perspective on workplace flexibility.
 
 
 
 This is a hybrid position open to candidates residing in Wayne or Macomb County, Michigan. The role requires approximately 50% travel to member homes within these counties.
 
 
 
 
 Position Purpose
 
 Develops, assesses, and facilitates complex care management activities for primarily physical needs members to provide high quality, cost-effective healthcare outcomes including personalized care plans and education for members and their families.
 
 
 <ul>
 <li>
 Evaluates the needs of the member, barriers to accessing the appropriate care, social determinants of health needs, focusing on what the member identifies as priority and recommends and/or facilitates the plan for the best outcome
 </li>
 <li>
 Develops ongoing care plans / service plans and collaborates with providers to identify providers, specialists, and/or community resources to address member's unmet needs
 </li>
 <li>
 Identifies problems/barriers to care and provide appropriate care management interventions
 </li>
 <li>
 Coordinates as appropriate between the member and/or family/caregivers and the care provider team to ensure members are receiving adequate and appropriate person-centered care or services
 </li>
 <li>
 Provides ongoing follow up and monitoring of member status, change in condition, and progress towards care plan / service plan goals; collaborate with member, caregivers, and appropriate providers to revise or update care plan / service plan as necessary to meet the member's goals / unmet needs
 </li>
 <li>
 Provides resource support to members and care managers for local resources for various services (e.g., employment, housing, participant direction, independent living, justice, foster care) based on service assessment and plans, as appropriate
 </li>
 <li>
 Facilitate care management and collaborate with appropriate providers or specialists to ensure member has timely access to needed care or services
 </li>
 <li>
 May perform telephonic, digital, home and/or other site outreach to assess member needs and collaborate with resources
 </li>
 <li>
 Collects, documents, and maintains all member information and care management activities to ensure compliance with current state, federal, and third-party payer regulators
 </li>
 <li>
 Provides and/or facilitates education to members and their families/caregivers on disease processes, resolving care gaps, healthcare provider instructions, care options, referrals, and healthcare benefits
 </li>
 <li>
 Provides feedback to leadership on opportunities to improve and enhance care and quality delivery for members in a cost-effective manner
 </li>
 <li>
 Other duties or responsibilities as assigned by people leader to meet business needs
 </li>
 <li>
 Performs other duties as assigned.
 </li>
 <li>
 Complies with all policies and standards.
 
 
 </li>
 </ul>
 
 Education/Experience
 
 Requires a Degree from an Accredited School of Nursing or a Bachelor's degree in Nursing and 2 &ndash; 4 years of related experience.
 
 
 
 License/Certification
 
 
 
 <ul>
 <li>
 RN - Registered Nurse - State Licensure and/or Compact State Licensure required
 
 
 </li>
 </ul>
 Pay Range $56,200.00 - $101,000.00 per year
 
 
 Centene offers a comprehensive benefits package including competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.
 
 
 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.
 
 
 Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act
</div>

Care Manager (RN)

Explore 5+ Medicare advantage rn review analyst in Michigan this May. Find roles across top companies and apply now to boost your career.

5 medicare advantage rn review analyst jobs In Michigan

Medicare Advantage RN Review Analyst

Medical Review Nurse Analyst

Case Management Nurse

Coder Abstractor - General Surgery - REMOTE

Care Manager (RN)