Are you an experienced nurse with a passion for claims review and utilization management? CAP Global Works, LLC, is seeking a skilled Claims Review Management Nurse to join our team. If you thrive in a dynamic, collaborative environment and have a knack for problem-solving, this advanced-level position could be the perfect fit for you!
As a Claims Review Management Nurse - Advanced, you’ll play a pivotal role in supporting Pennsylvania’s Medicaid program management and operations. This is an advanced-level position, meaning you’ll work independently, tackle complex challenges, and serve as a go-to resource for intricate questions. Your expertise will directly impact the efficiency and effectiveness of claims review processes, making a real difference in the healthcare landscape.
Schedule: Monday through Friday, 7:30 AM – 4:00 PM
Location: OMAP – Policy, Analysis and Planning, 625 Forster Street, Harrisburg, PA 17120
In this role, you will: - Provide leadership and oversight for projects and operational processes. - Participate in management workgroups and project teams. - Evaluate and implement system enhancements to improve efficiency. - Analyze existing processes and recommend improvements. - Develop resolutions to operational issues through data analysis. - Serve as a liaison between the Department and external stakeholders. - Assist in developing training programs related to claims review and processing. - Review coding and procedure code groupings. - Support claims processing decisions and provider billing inquiries. - Learn and serve as a resource for PROMISe processing functions.
To excel in this role, you’ll need: - An active Pennsylvania Registered Nurse License. - At least five (5) years of utilization review experience. - Comprehensive knowledge of utilization review processes and criteria. - Experience with coding, claims review, and utilization management. - Basic computer skills, including proficiency in Microsoft Office products.
At CAP Global Works, LLC, we pride ourselves on fostering a professional and collaborative work environment. We value expertise, innovation, and a commitment to excellence. As part of our team, you’ll have the opportunity to work on meaningful projects that make a tangible impact on healthcare operations in Pennsylvania.
If you’re ready to take your career to the next level and contribute your expertise to a forward-thinking organization, we’d love to hear from you! Apply today and let’s work together to shape the future of claims review management.
