Compliance Review Team Lead

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...

About the RoleThe Facility Compliance Review team reviews post-service prepayment facility claims for contract compliance, industry billing standards, medical necessity, and hospital-acquired conditions/never events. As a Utilization Management Nurse, Senior, you will report to the Senior Manager, Facility Compliance Review.

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 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...

**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...

Job SummaryWe are seeking an experienced UM Nurse, LVN to join our team at Advanced Medical Management. As a key member of our utilization management team, you will play a critical role in ensuring that our members receive the highest level of care while also helping us optimize resource allocation.In this role, you will be responsible for conducting...

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...

Compliance Specialist - Affordable HousingAbout Us:Avanath is a leading provider of affordable housing solutions, dedicated to making a positive impact on the lives of hardworking American families.Job Summary:We are seeking a highly skilled and detail-oriented Compliance Specialist to join our team. As a Compliance Specialist, you will be responsible for...

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...

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...

Job Summary:In this dynamic role, you will lead the Bakery team at Whole Foods Market to deliver exceptional customer experiences and drive business growth. As a Bakery Team Lead, you will be responsible for overseeing all aspects of daily operations, including profitability, expense control, buying, merchandising, labor, regulatory compliance, and special...

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 Title: Medical Record Review and Analysis ManagerAbout Our Organization: Molina Healthcare is a mission-driven organization dedicated to improving the lives of our members and the communities we serve. We are seeking an experienced Medical Record Review and Analysis Manager to join our team.Salary: The estimated annual salary for this position is around...

Overview:">">Volt is a leading provider of staffing solutions, and we are seeking a highly skilled Regulatory Administrator to join our team. As a Regulatory Administrator, you will play a crucial role in ensuring compliance with regulatory requirements for our clients. Job Summary:">We are looking for an experienced Regulatory Administrator to coordinate...

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...

Job Description:The Clinical Coding Analyst RN, Consultant role is a vital part of our team at Blue Shield of California. We are committed to ensuring the highest level of care and compliance in our services.Company Overview:We pride ourselves on delivering exceptional healthcare services that prioritize patient well-being. Our team works tirelessly to...

Job Title: Clinical Reviewer LVNJob Type: Full-timeLocation: RemoteAbout Us:At Advanced Medical Manage, we are dedicated to providing high-quality healthcare services to our members. We are seeking an experienced Clinical Reviewer LVN to join our team.Job Summary:The Clinical Reviewer LVN will be responsible for reviewing requests for service authorizations...

About the Position:Molina Healthcare is seeking a highly skilled Clinical Review Nurse to join our team as a SIU Investigator. As a Clinical Review Nurse, you will be responsible for reviewing and analyzing information to make medical determinations and applying clinical knowledge to assess the medical necessity of services.Responsibilities:Review and...

**Job Overview:**Transformational Living Homes, Inc. is seeking a skilled Grant Compliance Accountant to join our team. In this role, you will be responsible for overseeing the complete grant lifecycle, from acquisition to reporting.Key Responsibilities:Enter, verify, and reconcile all financial data and transactions related to grants.Analyze grant-related...

Job Summary: Molina Healthcare Services is seeking a seasoned Care Management Team Lead to oversee an integrated team responsible for case management, community connectors, health management, and/or transition of care activities. This role plays a crucial part in assisting members with their healthcare needs by promoting optimal clinical, financial, and...