| Medical Claims Review Manager Job Description |
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| The following is a full job description for Medical Claims Review Manager. Here are the requirements and responsibilities for Medical Claims Review Manager along with statistics. If after reading this page you determine that Medical Claims Review Manager is not the position you are looking for, you may want to try one of these similar titles: Claims Manager, Claims Manager, Senior, Medical Utilization Review Manager, Claims Examiner I, Claims Examiner II, Claims Examiner IV, Claims Examiner III, Disability Claims Examiner III, Medical Utilization Review Senior Manager |
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| Requirements and Responsibilities For Medical Claims Review Manager |
| Manages the medical claims review function to ensure accurate, compliant, and clinically appropriate adjudication of medical claims. Oversees a team of reviewers, examiners, or clinical staff responsible for evaluating coverage, coding, and medical necessity. Develops review procedures, quality standards, and performance metrics to ensure consistency and regulatory compliance. Reviews complex, high-dollar, or escalated claims and provides clinical and technical guidance to staff. Analyzes review outcomes, denial trends, and error patterns to drive continuous improvement. Ensures compliance with company guidelines, applicable payer requirements, and regulatory standards. Requires a bachelor's degree. Typically reports to a director. Manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. Typically requires 5 years experience in the related area as an individual contributor. 1-3 years supervisory experience may be required. Extensive knowledge of the function and department processes. |
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| Also referred to as: Medical Claims Examination Manager, Medical Claims Quality Nurse Manager |
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| Similar Jobs: Claims Manager, Claims Manager, Senior, Medical Utilization Review Manager, Claims Examiner I, Claims Examiner II, Claims Examiner IV, Claims Examiner III, Disability Claims Examiner III, Medical Utilization Review Senior Manager |
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| Level of Education: Medical Claims Review Manager Salaries with a Bachelor's Degree, Medical Claims Review Manager Salaries with a Master's Degree or MBA, Medical Claims Review Manager Salaries with a JD, MD, PhD or Equivalent |
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| Industries: Edu., Gov't. & Nonprofit, Healthcare, Insurance | |
