Surveillance Utilization Review Manager

Descripción del Empleo:
• Responsible for monitoring referral patterns and making recommendations on
strategies to contain costs, improve access and insure quality care.
• Prepares statistical and narrative reports on utilization patterns, expenditures by area
and revenue stream, demographics of service delivery and trending of expenditures by
program.
• Monitors and analyzes the use of services from providers.
• Trains professional clinic and program staff on current principals and standards of practice of Utilization Management, medical/surgical diagnosis and treatment coding and reimbursement methodologies.
Requisitos:
• Bachelor's degree • Healthcare Industry background • Identifies aberrant billing practices
• Educates those who have improperly billed the Medicaid program
• Recovers overpayments, recommends sanctions for those who abusively bill Medicaid
• Assists in criminal investigations when appropriate
• Detects areas where Medicaid regulations and/or policy may be modified, administers the provisions of the False Claims Acts
• Conducts provider training on fraud, waste, abuse, and improper payments, and prevents fraud and abuse from occurring.
• Medical experience in hospital, clinic, mental health or pharmacy
• Experience with utilization review procedures and techniques
• Familiar with medical and surgical diagnoses codes and procedures codes
• Experience in statistical data collection and interpretation
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