Manager, A&G Clinical Review

Overview

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.

Why work for MJHS?

When you work with us you will receive comprehensive and affordable health and financial benefits, in addition to generous paid vacation, personal and holiday time that you won't find at our competitors. Do you receive a paid day off for your birthday now? No?  You will here!  You will also receive the training, tuition assistance and career development you desire to help you achieve your career goals.  You take care of our patients, residents and health plan members, and we will take care of the rest!

 

Benefits include:

• Sign-on Bonuses OR Student Loan Assistance for clinical staff
• FREE Online RN to BSN and MSN degree programs!
• Tuition Reimbursement for all full and part-time staff
• Dependent Tuition Reimbursement for clinical staff!
• Generous paid time off
• Affordable medical, dental and vision coverage for employee and family members
• Two retirement plans! 403(b) AND Employer Paid Pension
• Flexible spending
• And MORE!

 

MJHS companies are qualified employers under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF)

Responsibilities

Responsible for direct oversight and management of clinical review processes within Appeals & Grievances Department. Ensures regulatory compliance and timely processing for the Medicare and Medicaid appeal and grievance processes, quality of care concerns and any other inquires requiring clinical review for medical necessity, appropriateness of service or clinical quality. Acts as subject matter expert to internal departments and delegated vendors to assure all are educated and complaint with requirements of appeals and grievance regulations and processing

Qualifications

• Bachelor’s Degree required. Master’s preferred
• 5 plus years’ experience in managed care including appeals and grievance and/or compliance
• 2 years’ prior supervisory or management experience required
• Strong knowledge of federal, state and managed healthcare regulations and requirements
• NYS RN License Degree. Strong leadership skills
• Detail oriented. Excellent computer software skills including Microsoft Office, Access, PowerPoint, MS Project

Min

USD $115,104.83/Yr.

Max

USD $143,881.04/Yr.