Grievance and Appeals Nurse

Job SummaryWe are seeking a highly skilled Grievance and Appeals Nurse to join our team at Alura Workforce Solutions. The successful candidate will be responsible for working directly with IPAs, hospitals, internal departments, and the grievance team to ensure grievance and appeal cases are processed in accordance with our Grievance Policy & Procedures and...

Grievance and Appeals Nurse - Hybrid Job DescriptionHealthCare Support is seeking a skilled Grievance and Appeals Nurse - Hybrid to join their team. This role involves working closely with the Grievance and Appeals Team to ensure all member grievance issues are investigated and resolved appropriately.Daily Responsibilities:Work with the Grievance and Appeals...

Grievance and Appeals Nurse - Hybrid Job SummaryHealthCare Support is seeking a Grievance and Appeals Nurse - Hybrid to fill an opening with a Fortune top 25 Managed Care Company in Rancho Cucamonga, CA. This is a 6-month contract position, with the possibility of transitioning to an internal role after completion. The successful candidate will work Monday...

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)...

About the RoleThe Appeals and Grievances team at Blue Shield of California is seeking a skilled RN Senior to join our team. As a Clinical Reviewer, you will play a critical role in ensuring that member appeals and grievances are handled in a timely and accurate manner.Key ResponsibilitiesConduct thorough clinical reviews of member-initiated appeals and...

About the RoleWe are seeking a skilled Clinical Reviewer to join our Appeals and Grievances team at Blue Shield of California. As a key member of our team, you will play a critical role in ensuring that our members receive high-quality care and that our clinical decisions are informed by the latest evidence-based guidelines.Key ResponsibilitiesConduct...

About the RoleWe are seeking a highly skilled Medical Director, Utilization Management to join our team at Blue Shield of California. As a key member of our Medical Management department, you will play a critical role in ensuring our members receive the right level of care, at the right time, and at the right cost.Key ResponsibilitiesReview and make...

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 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 Title: Medicare Prior Authorization RNAt Blue Shield of California, we are seeking a skilled and experienced Medicare Prior Authorization RN to join our Utilization Management team. As a key member of our team, you will play a critical role in ensuring that our members receive high-quality, cost-effective care.Key Responsibilities:Conduct thorough...

Job SummaryBlue Shield of California is seeking a highly skilled Medical Director, Utilization Management to join our team. As a key member of our Medical Management department, you will play a critical role in ensuring our Medi-Cal members receive the right level of care, at the right time, and at the right cost.The ideal candidate will have a strong...

About the RoleBlue Shield of California is seeking a highly skilled Senior Care Manager to join our team. As a key member of our Care Management team, you will play a critical role in supporting the mission of our department, which is to provide exceptional care and support to patients in the outpatient setting.Key Responsibilities:Develop and implement...

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 SummaryThis role is part of the Care Management team at Blue Shield of California, supporting the mission of providing support to patients in maintaining health and wellness in the outpatient setting. As a Senior Care Manager, you will ensure that services are provided based on standardized procedures, including coordination of care with specialists,...

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...

About the RoleBlue Shield of California is seeking a highly skilled Medical Director Operations Lead to provide clinical leadership within the Medical Management department. This role will oversee clinical review activities, including utilization management, appeals, and grievances. The successful candidate will have a strong background in healthcare...

About the RoleThe Utilization Management Nurse, Senior will play a critical 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 evidence-based guidelines, policies, and nationally recognized clinical criteria.Key ResponsibilitiesPerform...

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...

Your RoleThe Care Management team at Blue Shield of California aims to support the mission of the department, which is to provide care and support to patients in maintaining health and wellness in the outpatient setting.In this role, you will work closely with the Manager of Care Management to ensure that services are provided based on standardized...