Appeals and Grievances Clinical Reviewer

About the RoleWe are seeking a highly skilled Appeals and Grievances Representative to join our team at Blue Shield of CA. As a key member of our Medi-Cal Appeals and Grievance team, you will be responsible for researching and resolving member grievances, appeals, and interpreting health plan benefits, policies, and procedures.Key ResponsibilitiesAssist with...

Job SummaryWe are seeking a highly skilled and experienced Grievance and Appeals Nurse to join our team at Alura Workforce Solutions. As a key member of our healthcare team, you will be responsible for ensuring that grievance and appeal cases are processed in accordance with regulatory guidelines and company policies.Key ResponsibilitiesWork closely with...

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...

HealthCare Support is seeking a skilled Grievance and Appeals Nurse to join our team. As a Grievance and Appeals Nurse, you will work closely with our Grievance and Appeals Team to investigate and resolve member grievances in a timely and effective manner. Your responsibilities will include reviewing case coding, assisting in the resolution of member medical...

HealthCare Support is seeking a skilled Grievance and Appeals Nurse to join our team. As a key member of our team, you will work closely with the Grievance and Appeals Team to ensure all Member grievance issues are investigated and resolved appropriately. Your responsibilities will include reviewing case coding, assisting in the resolution of Member medical...

Grievance and Appeals Nurse - Hybrid Job DescriptionWe are seeking a skilled Grievance and Appeals Nurse - Hybrid to join our team at HealthCare Support. As a key member of our team, you will work closely with the Grievance and Appeals Team to ensure all Member grievance issues are investigated and resolved in a timely and effective manner.Key...

Grievance and Appeals Nurse - Hybrid PositionHealthCare Support is seeking a skilled Grievance and Appeals Nurse to fill a hybrid role with a top 25 Managed Care Company in Rancho Cucamonga, CA.Key Responsibilities:Work closely with the Grievance and Appeals Team to investigate and resolve Member grievances.Review case coding and assist in the resolution of...

Your RoleAs a key member of the Blue Shield of CA team, you will play a critical role in ensuring that our members receive the highest level of service and support. The Appeals and Grievances Representative will be responsible for researching and resolving member grievances and appeals, as well as interpreting and explaining health plan benefits, policies,...

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...

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 Medi-Cal members receive the right level of care, at the right time, and at the right cost.Key ResponsibilitiesReview and make...

Job SummaryWe are seeking a highly skilled Medical Director, Operations 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 determinations...

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 RoleWe are seeking an Advanced Provider Dispute Resolution Coordinator to join our Provider Dispute Resolution Team. As a key member of our team, you will be responsible for researching, reviewing, and resolving high-level/high-priority provider grievances, appeals, and complaints.Key ResponsibilitiesProcess provider appeals and correspondence with...

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 RoleWe are seeking a skilled Clinical Review Nurse to join our team at Actalent. As a Clinical Review Nurse, you will play a critical role in ensuring that our clients receive high-quality care and services.Key ResponsibilitiesConduct thorough reviews of medical records to ensure accuracy and completenessCollaborate with healthcare professionals to...

Your RoleThe Commercial Post Service Review team at Blue Shield of California is responsible for clinically reviewing claims that are the result of either a preservice or claim denial. As a Senior Clinical Reviewer, you will report to the Manager, Post Service, and perform accurate and timely clinical review of post service claims for the CalPERS...

Job SummaryBlue Shield of California is seeking a skilled Senior Clinical Review Nurse to join our Commercial Post Service Review team. As a key member of our team, you will be responsible for clinically reviewing claims that are the result of either a preservice or claim denial.Key ResponsibilitiesPerform accurate and timely clinical review of post service...

About the RoleWe are seeking a highly skilled Medical Director 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 ResponsibilitiesDevelop and deploy medical management...

About the RoleThe Clinical Quality Review team at Blue Shield of California is seeking a seasoned leader to oversee the review of potential quality issues that impact our members, providers, and staff. As a key member of our Quality Management and Assurance team, you will work closely with medical directors to identify and address quality concerns, ensuring...