We have other current jobs related to this field that you can find below
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Rancho Cordova, California, United States Blue Shield of California Full timePosition OverviewThe Utilization Management division is responsible for evaluating inpatient admissions for our members, adhering to established standards of care. The Senior Utilization Management Nurse will work under the supervision of the Utilization Management Nurse Manager. In this capacity, you will be tasked with reviewing clinical data from various...
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7 days ago
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Case Management
7 days ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Care Management team will serve to support the mission of the department, which is to provide support to patients in maintaining health and wellness in the outpatient setting. The Senior Care Manager will report to the Manager of Care Management. In this role you will ensure that services are provided based on standardized procedures...
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Case Management
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Rancho Cordova, United States Blue Shield of California Full timeYour Role The Care Management team will serve to support the mission of the department, which is to provide support to patients in maintaining health and wellness in the outpatient setting. The Senior Care Manager will report to the Manager of Care Management. In this role you will ensure that services are provided based on standardized procedures...
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Case Management
2 months ago
Rancho Cordova, United States Blue Shield of California Full timeYour Role The Care Management team will serve to support the mission of the department, which is to provide support to patients in maintaining health and wellness in the outpatient setting. The Senior Care Manager will report to the Manager of Care Management. In this role you will ensure that services are provided based on standardized procedures...
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Registered Nurse Senior
2 months ago
Summary:
The Medi-Cal Member Appeals and Grievances team is responsible for clinically reviewing member appeals and grievances that are the result of either a preservice, post-service or claim denial. The Medi-Cal Appeals and Grievances RN Senior will report to the Appeals and Grievances Manager. In this role you will perform accurate and timely clinical review of Member-initiated appeals. The RNs perform first level appeal reviews for members utilizing the National Coverage Determination (NCD) guidelines, Local Coverage Determination (LCD) Guidelines, Milliman Care Guidelines, and nationally recognized sources such as NCCN and ACOG.
In this role you will also perform Clinical oversight of all Medi-Cal grievances. In this process, the candidate will work with the medical directors and coordinators to identify any Potential Quality Issues (PQI), Quality of Service (QOS) cases and/or Quality of Care (QOC) cases to ensure member’s clinical needs are addressed appropriately within 30 days or 72 hours if the request is deemed expedited.
Responsibilities:
· Identify issues, and with assistance, execute corrective action
· Intake Queue
· Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination
· Communicates determinations to the providers in compliance with state, federal and accreditation requirements
· Works well in a fast paced, production environment
· Initiates appropriate referrals for members’ needs to other departments such as Case Management.
Knowledge and Experience:
· Requires a current CA RN License
· Requires at least 5 years of prior experience in nursing, healthcare or other related fields
· Knowledge of Medicare and Medi-Cal and benefit reviews
· Knowledge of CPT, ICD-10, HCPCS and billing practices
· Demonstrate the ability to act independently using sound clinical judgement
Values:
· Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short
· Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes
· Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals
Compensation:
The pay rate range above is the base hourly pay range that Aditi Consulting reasonably expects to pay someone for this position (compensation may vary outside of this range depending on several factors, including but not limited to, a candidate’s qualifications, skills, competencies, competencies, competencies, competencies, experience, location and end client requirements).
Benefits and Ancillaries:
Medical, dental, vision, PTO benefits and ancillaries may be available for eligible Aditi Consulting employees and vary based on the plan options selected by the employee.