Clinical Reviewer
1 day ago
We 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 Responsibilities- Conduct thorough clinical reviews of member-initiated appeals and grievances, ensuring that all relevant information is considered and that decisions are made in accordance with our policies and procedures.
- Collaborate with our Medical Director to ensure that all clinical decisions are informed by the latest evidence-based guidelines and that our members receive the highest level of care.
- Communicate with members and providers to ensure that all parties are informed of the status of their appeals and grievances and that any necessary actions are taken.
- Stay up-to-date with the latest clinical guidelines and policies, ensuring that our team's knowledge and expertise are current and relevant.
- Bachelor's degree in Nursing or advanced degree preferred.
- Current California RN License required.
- At least 5 years of prior relevant experience in clinical review or a related field.
- Proficient skills with Microsoft Office Suite.
- Knowledge of CPT, ICD-10, HCPCS, and billing practices.
- Knowledge of medical policy and benefit reviews preferred.
As a Clinical Reviewer at Blue Shield of California, you will have the opportunity to work in a dynamic and supportive environment that values your expertise and contributions. We offer a competitive salary range of $87,230 to $130,900, depending on experience, as well as a comprehensive benefits package and opportunities for professional growth and development.
About Blue Shield of CaliforniaBlue Shield of California is a nonprofit health plan dedicated to making a positive impact on the health and well-being of our members and the communities we serve. We are committed to providing high-quality care and services that meet the unique needs of our members, while also promoting health equity and addressing social determinants of health.
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