Supervisor, Medicare Risk Optimization

Supervise the Retrospective Review Department's Medicare Risk Optimization staff by handling the day-to-day operations for the following functions.
1. Completion of retrospective reviews of suspected clinical condition(s), including internal and external components.
2. Prospective New Enrollee contacts to ensure capture and validation of member reported conditions.
3. Administrative support related to Medicare Risk Optimization.

ESSENTIAL JOB FUNCTIONS:

1.Monitor and track timeliness and accuracy of internal reviews to evaluate and capture suspect conditions
generated by Plan Data Management application/Health Plan.
2.Review and decide on the appropriateness of recommendations for external reviews when a suspect condition cannot be satisfied by the internal review process, but is deemed highly probable based on Clinician's judgment.
3.Oversees New Enrollee Health Status Survey function to ensure timely contact, identification, validation and follow-up of member reported conditions.
4.Supervise Administrative Reviewer to assure accurate and comprehensive data entry for data collected from the prospective, as well as internal and external review(s) related to the Medicare Optimization Function.
5.Conduct/ supervise external fields reviews when warranted.

Education/Experience:

-Registered Nurse with current Florida license
-3-5 years of clinical experience with acute and medical-surgical clinical background
-Medical Terminology required
-Prior Supervisory experience strongly preferred
-Basic tying skills required
-Advanced ability to perform internet-based research required
-Working knowledge of Microsoft Excel required
-Working knowledge of Microsoft Word experience required
-Milliman/InterQual knowledge required
-Coding knowledge required (HCPCS, CPT, ICD9)




AvMed Health Plans is a Drug-Free Workplace, EOE.