Clinical Review Specialist, Senior

Job SummaryThe Clinical Review Specialist, Senior at Blue Shield of California will lead retrospective utilization reviews and 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 and FEP.Key...

At Blue Shield of California, we're seeking an experienced Senior Clinical Utilization Review Nurse to join our Facility Compliance Review team. This role is ideal for a highly skilled professional who can ensure medical necessity and billing standards are met.Key Responsibilities:Conduct retrospective utilization reviews and first-level determination...

OverviewAt Blue Shield of California, we are committed to delivering high-quality healthcare services. Our Utilization Management team plays a vital role in ensuring that our members receive the best possible care.In this exciting opportunity, you will work as a Clinical Review Nurse, Senior - Utilization Management, and be responsible for reviewing medical...

**Overview of Blue Shield of CaliforniaWe are a not-for-profit health plan that provides high-quality healthcare services to millions of Californians. Our mission is to make a meaningful difference in the lives of our members by delivering innovative, patient-centered care.About the RoleWe are seeking an experienced Clinical Review Specialist - Utilization...

About the RoleAs a senior member of the Facility Compliance Review team at Blue Shield of California, you will play a critical role in ensuring that post-service prepayment facility claims are thoroughly reviewed for contract compliance, industry billing standards, medical necessity, and hospital-acquired conditions/never events. Reporting directly to the...

Job OverviewThe Medical Claims Review Specialist will be responsible for reviewing facility claims to ensure compliance with medical necessity and billing standards. This role involves conducting retrospective utilization reviews, preparing cases for medical director oversight, and ensuring adherence to regulatory and accreditation requirements.Key...

Job SummaryWe are seeking a Senior Clinical Coordination Specialist to oversee patient care coordination in outpatient settings and promote health and wellness.About the Role:Develop individualized care plans to ensure appropriate management of patient needs.Collaborate with healthcare professionals to coordinate patient care and services.Conduct health...

Senior Healthcare Compliance Specialist Job DescriptionIn this challenging role, you will be responsible for conducting retrospective utilization reviews to ensure compliance with medical necessity and billing standards.The ideal candidate will possess strong analytical skills and effective communication to manage claims and improve quality of care. You will...

Job Summary:Molina Healthcare Services works with members, providers and multidisciplinary team members to assess, facilitate, plan and coordinate an integrated delivery of care across the continuum. This includes behavioral health and long term care for members with high need potential. Our staff work to ensure that patients progress toward desired outcomes...

Role Overview:The Clinical Coding Analyst RN Senior will be responsible for performing in-depth quality audits of hospital claims to support ICD-10-CM and ICD-10 PCS codes, as well as MS-DRG and APR-DRG reviews based on clinical determination. This role requires a strong understanding of medical necessity and reimbursement requirements, as well as the...

Job OverviewWe are seeking a seasoned Clinical Coding Analyst RN, Senior to join our Facility Compliance Review team at Blue Shield of California.

About the RoleAre you a detail-oriented healthcare professional with a passion for delivering high-quality care? Blue Shield of California is seeking a skilled Clinical Coding Analyst RN, Senior to join our team. As a member of our Facility Compliance Review team, you will play a critical role in ensuring the accuracy and integrity of medical coding for our...

At Blue Shield of California, we're seeking a highly skilled Healthcare Compliance Specialist to join our Facility Compliance Review team. As a key member of this team, you will play a vital role in reviewing post-service prepayment facility claims for contract compliance, industry billing standards, medical necessity, and hospital-acquired conditions/never...

About the RoleWe are seeking a skilled Senior Care Manager to join our Care Management team at Blue Shield of California. As a key member of our team, you will play a vital role in ensuring the delivery of quality and cost-effective healthcare services to our patients.Job SummaryThe Senior Care Manager is responsible for coordinating care for patients in an...

About the OpportunityWe are seeking a highly skilled Senior Accounts Payable Specialist to join our team. As a key member of our finance department, you will be responsible for coordinating paperwork with receiving and purchasing departments, investigating discrepancies on large supplier accounts, matching and batching AP, reviewing orders for accuracy, and...

Job OverviewWe are a rapidly growing company, Valyrian Consultants Inc, seeking an experienced Senior Sales Development Specialist to join our exceptional team. The ideal candidate will be a true sales professional with the ability to bring unique value to our organization.

Critical Role in Enhancing Healthcare QualityThe Senior Clinical Quality Analyst plays a vital part in elevating healthcare quality performance through intricate data analysis and reporting. This position demands the development of sophisticated data systems, the execution of high-level analyses for enhancing healthcare quality metrics, and collaboration...

About the Role:We are seeking a skilled Clinical Specialist to join our team at CoapTech, a Baltimore-based medical device company. The successful candidate will play a critical role in the commercialization of our PUMA System, a platform that enables minimally invasive, bedside medical procedures.Responsibilities:Function under the direction of the...

Company OverviewSCAN Health Plan is a leading health care organization dedicated to providing innovative solutions that improve the lives of our members and community.We are seeking an experienced Senior Business Solutions Specialist to join our team. As a key member of our business intelligence group, you will play a critical role in transforming health...

**About Blue Shield of California**We are a health plan committed to providing high-quality healthcare services to our members. As a Senior Health Care Manager, you will play a key role in supporting the mission of our department.**Job Summary**This is a challenging and rewarding role that requires strong clinical judgment, communication skills, and...