QuestPro Consultants is partnering with a growing, but well respected commercial insurance organization seeking a passionate leader to join their team.. Use your knowledge and talent to provide oversight to key elements of their corporate claim medical management programs. As a member of the medical management services leadership team, you will have primary responsibility for: Provider Relations and Utilization Review, and the pharmacy benefit system which includes the drug cost on Workers’ Compensation claims and price comparison for regions. In addition, you will assist with the client's Medical Billing and Medical Allocation programs. In this key role, you will work with our client's talented team of medical professionals to ensure quality& timely medical service deliverables in support of their corporate claim philosophy. Collaborate with claim management to determine the scope and content of medical cost projections, Medicare set-aside analysis and life care plans. Provide oversight for the daily operations of the assigned team, and leadership to ensure cross training of the assigned medical management resources to enhance teamwork, productivity, efficiencies and succession planning. Provide continuous improvement and evaluation of specialty medical requirement programs, as well as identify opportunities to implement best practices that will drive efficiencies and profitability.

Education and Qualifications:

• Bachelor’s Degree (Nursing Preferred)
• Minimum of six years of relevant medical management experience and two years in supervisory role
• Medical Management Operations Management experience; (Insurance environment preferred)
• Advanced knowledge of individual state medical bill processing requirements.
• Advanced knowledge of Workers' Compensation Reimbursement Manual Guidelines.
• Advanced working knowledge of utilization review/quality assurance policies and procedures.
• Advanced knowledge of EDI processes for all state medical filings.
• Intermediate knowledge of coding (ICD-10, CPT, Procedural) and medical terminology.
• Intermediate knowledge of insurance forms and rules.

Preferred

• Nursing experience and CMS/MSA experience
• An active and current registered nurse license
• Certification in at least two of the following: Life Care Planning (LCP), Medicare Set Aside Consultant Certified (MSCC), Certified Case Manager (CCM), Certification of Disability Management Specialist (CDMS), Certified Rehabilitation Registered Nurse (CRRN), or Certified Legal Nurse Consultant (CLNC)