Clinical Quality Review Manager

Job DescriptionYour RoleThe Medical Care Solutions education team is responsible for all clinical education for all departments within Medical Care Solutions as well as some Health Solutions teams. This includes Utilization Management, Care Management, Post Service, and Appeals. This clinical educator role will be responsible for Utilization Management for...

About the RoleBlue Shield of California and Promise Health Plan are seeking a skilled Clinical Quality Analytics and Informatics professional to join our team. As a Clinical Quality Analyst - Senior, you will play a critical role in delivering high-quality clinical analytics and informatics to support our mission of providing excellent member-centered...

Your RoleThe Blue Shield Behavioral Health Clinical Strategy and Programs team collaborates with internal and external partners to develop, execute, and evaluate Blue Shield of CA's behavioral health and addiction medicine strategy, referred to as "Behavioral Health, Re-Imagined." As a Clinical Strategy and Programs Manager, you will work with...

Your RoleThe Medical Management team at Blue Shield of California is dedicated to ensuring that our organization is at the forefront of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system in California. As the Medical Director, Utilization Management (CalPERS), you will report to the Vice President, Medical...

Job SummaryThe Senior Utilization Management Nurse will be responsible for performing first-level determination approvals for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare. This role requires a strong clinical judgment and...

Your Role:As a Clinical Appeals and Grievances Specialist at Blue Shield of California, you will be responsible for reviewing member appeals and grievances related to Medicare and Medi-Cal benefits. This role requires a strong understanding of clinical guidelines, including National Coverage Determination (NCD) and Local Coverage Determination (LCD)...

Job SummaryThe Senior Utilization Management Nurse will be responsible for reviewing inpatient stays for our members under nationally recognized levels of care guidelines. This role requires a strong clinical background and excellent analytical skills to determine medical necessity of admissions, appropriate length of stay, and level of care.Key...

Job SummaryThe Senior Utilization Management Nurse will play a key role in ensuring that members receive high-quality, cost-effective care. This position will be responsible for performing first-level determination approvals for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria.Key ResponsibilitiesPerform...

Job SummaryAs a Quality Assurance Director at Demo - Maximus, you will be responsible for developing and implementing quality assurance systems and goals to ensure compliance with contractual and regulatory requirements. You will work closely with the Department of Health Care Services to develop and maintain positive and effective communications.Key...

About the RoleThe Utilization Management Nurse, Senior will play a critical role in ensuring the quality and cost-effectiveness of healthcare services for our members.Key ResponsibilitiesConduct prospective, concurrent, and retrospective utilization reviews to determine medical necessity and ensure compliance with nationally recognized clinical...

Your RoleAs a Utilization Management Nurse, you will play a critical role in ensuring that our members receive the highest quality care while minimizing unnecessary costs. You will be responsible for reviewing inpatient stays and applying nationally recognized levels of care guidelines to determine medical necessity.Your WorkConduct thorough reviews of...

Job SummaryThe primary purpose of this position is to assist customers with their healthcare needs and maximize health outcomes by filling prescriptions, providing clinical services, advising on therapies, and providing excellent customer service. The incumbent is also required to perform all tasks in a safe manner consistent with Rite Aid policies and state...

Job Title: Clinical TechnicianAkua Behavioral Health is seeking a skilled Clinical Technician to join our team. As a Clinical Technician, you will play a vital role in supporting our clients in their recovery journey.Key Responsibilities:Provide support to clients during their shift, ensuring their safety and well-being.Conduct orientation to new clients,...

Your RoleAs a key member of the Utilization Management team at Blue Shield of California, the Director, Medicare & Medi-Cal Utilization Management plays a critical role in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal membership.This individual will lead the development of UM...

Cross Country Nurses is seeking a registered nurse to provide care for patients in a clinical setting. As a clinical nurse, you will treat patients who are ill, injured or undergoing surgery. You will administer medications, monitor vital signs, change dressings, manage IVs, provide patient and family education, and help with patient discharge in...

Job Title: Senior Quality ChemistJob Summary:We are seeking a highly skilled Senior Quality Chemist to join our team at AMPAC Fine Chemicals. As a Senior Quality Chemist, you will be responsible for analyzing and making determinations as to the quality of a product, using analytical equipment pertinent to the appropriate application of skills.Key...

About the RoleThe Medical Director, Utilization Management plays a critical role in ensuring the delivery of high-quality, cost-effective healthcare services to our members. As a key member of the Blue Shield of California Medical Management team, you will be responsible for reviewing and making determinations regarding member and provider requests for...

Job SummaryThe Medical Director, Utilization Management will serve as a key member of the Blue Shield of California Promise Health Plan's utilization management review team. This role reports to the VP, Medical Management or their designee.Key ResponsibilitiesReview and make determinations regarding all member and provider requests for service, including...

Your RoleThe Medical Director, Operations (Behavioral Health) will report to the Senior Medical Director, Behavioral Health at Blue Shield of California. In this role, you will have core responsibilities in the areas of psychiatric inpatient concurrent review, pre- and post-service utilization review, and collaboration with Nurse Care Managers.Key...

Cross Country Nurses is seeking a travel nurse RN Clinic for a challenging and rewarding travel nursing opportunity in a clinical setting.Job Description & RequirementsSpecialty: ClinicDiscipline: RNDuration: 13 weeks36 hours per weekShift: 12 hoursEmployment Type: TravelAs a registered nurse - clinic (RN), you will provide high-quality patient care in a...