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Medical Case Manager
CPS Recruitment, Inc. is now hiring for a full time Case Manager for full-time position in the Greater Rochester area.
This individual is responsible for the coordination and monitoring the use of healthcare services for managed care members ensuring compliance using both corporate standards as well as those set by external regulatory entities. Performing pricing, coding or medical necessity audits ensuring adherence to regulations is also part of this role. Individual will perform clinical review either telephonically or onsite depending on member need.
This position will also be responsible for utilization management and must have a complete understanding of clinical nursing, coding standards and health plan benefits. Will monitor and identify billing trends and refer cases to either Medical Director or Fraud Divisions.
Providing care coordination for members, will identify opportunities to integrate services and collaborate with hospital home care and other providers to ensure clinical needs are met, making referrals when necessary.
- NY State Registered Nurse/Licensed Practical Nurse or at least 4 years prior experience with Utilization Management, Case Management Review
- Excellent verbal and written communication skills along with strong organizational and multi-tasking skills
- Proficient computer skills
- Experience with the interpretation of health plan benefit documents
- Knowledge of CPT, HCPCS and ICD9-CM diagnosis and procedure coding with eventual formal coding education and certification (i.e. CPC, CPC-H, RHIT) is preferred
- Base knowledge of both Medicare and Medicaid guidelines preferred
If interested, contact our healthcare team for more details at (315) 457-2500
- Start Date:
- Pay Rate:
- Healthcare - Clinical
- Syracuse, NY 13214
- Job Type:
- Contract To Hire
- Job ID: