Current jobs related to Utilization Management Nurse, Senior - Long Beach, California - Blue Shield of California
-
Senior Utilization Management Nurse
2 weeks ago
Long Beach, California, United States Blue Shield of CA Full timeYour RoleThe Utilization Management team at Blue Shield of CA reviews inpatient stays for our members under nationally recognized levels of care guidelines.The Senior Utilization Management Nurse will report to the Utilization Management Nurse Manager.In this role, you will be assigned a list of inpatient facilities and review clinical information provided...
-
Senior Utilization Management Nurse
3 weeks ago
Long Beach, California, United States Blue Shield Of California Full timeJob SummaryWe are seeking a highly skilled Senior Utilization Management Nurse to join our team at Blue Shield of California. In this role, you will be responsible for reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. You will also be reviewing hospital itemized bills for a comprehensive line-by-line...
-
Senior Utilization Management Nurse
2 weeks ago
Long Beach, California, United States Blue Shield of CA Full timeJob 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...
-
Senior Nurse Manager
3 weeks ago
Long Beach, California, United States Quality Talent Group Full timeAbout the RoleWe are seeking a highly skilled and experienced Registered Nurse (RN) to fill the position of Senior Nurse Manager at our Skilled Nursing Facility in the Bronx, NY.Key ResponsibilitiesSupervise and manage the nursing staff on assigned unitsDevelop and implement employment policies and proceduresMentor and provide clinical guidance to less...
-
Long Beach, California, United States MANAGEMENT APPLICATIONS, INC. Full timeJob Title: Senior IT Professional: Emphasys Elite and Oracle e-Business Suite SupportManagement Applications, Inc. is seeking a highly skilled Senior IT Professional to provide support and maintenance for Emphasys Elite and Oracle e-Business Suite applications. The ideal candidate will have significant experience in applications business analyst roles, with...
-
Senior Client Experience Manager
3 weeks ago
Long Beach, California, United States Vaco Full timeJob SummaryVaco is seeking a Senior Client Experience Manager to drive our client experience initiatives. This role will play a pivotal role in analyzing client feedback, coordinating the creation and distribution of surveys, developing training programs, managing digital reputation, and overseeing client-facing marketing materials.Key ResponsibilitiesClient...
-
Senior Care Manager
3 weeks ago
Long Beach, California, United States Blue Shield Of California Full timeAbout the RoleWe are seeking a highly skilled Senior Care Manager to join our team at Blue Shield of California. As a Senior Care Manager, you will play a critical role in supporting the mission of our department, which is to provide high-quality healthcare services to our members.Key Responsibilities:Develop and implement care plans that promote quality of...
-
Senior IT Operations Manager
4 weeks ago
Long Beach, California, United States Nautilus Management Services Inc Full timeJob SummaryWe are seeking a highly skilled Senior IT Operations Manager to join our team at Nautilus Management Services Inc. As a key member of our IT department, you will be responsible for managing and maintaining our organization's IT infrastructure, including hardware and software, networks, servers, and storage devices.Key ResponsibilitiesIT...
-
Audit Manager and Senior
4 weeks ago
Long Beach, California, United States Affinity Executive Search Full timeExceptional Career Opportunities for Audit Managers and SeniorsWe are seeking highly skilled Audit Managers and Seniors to join our team at a well-established, highly profitable CPA firm. As a hybrid employee, you will work from both our office and your home with flexible hours, enjoying a reasonable work/life balance and diverse SEC and closely held clients...
-
Nurse Utilization Manager
4 weeks ago
Hermosa Beach, California, United States PIH Health Full timeJob SummaryWe are seeking a skilled Registered Nurse to join our Utilization Management team at PIH Health. As a Utilization Management RN, you will play a critical role in ensuring that patients receive the most appropriate level of care, while also meeting the needs of our healthcare system.Key ResponsibilitiesPerform utilization review activities,...
-
Senior Project Manager
3 weeks ago
Long Beach, California, United States Harris & Associates Full timeJob OverviewHarris & Associates is seeking a highly skilled Senior Project Engineer to join our dynamic Program & Construction Management team in Los Angeles, California. As a key member of our team, you will be responsible for managing and overseeing the day-to-day efforts related to program management of K-14 based projects, including programming,...
-
Senior Care Manager
4 weeks ago
Long Beach, California, United States Blue Shield Of California Full timeAbout the RoleWe are seeking a highly skilled and compassionate Senior Care Manager to join our team at Blue Shield of California. As a key member of our Care Management team, you will play a vital role in ensuring that our members receive high-quality, patient-centered care.Key ResponsibilitiesDevelop and implement individualized care plans that promote...
-
Senior Project Manager
4 weeks ago
Long Beach, California, United States Harris & Associates Full timeJob Title: Senior Project EngineerHarris & Associates is a 100% employee-owned company dedicated to delivering innovative solutions for complex infrastructure projects. Our team of experts is committed to excellence and collaboration, and we're seeking a skilled Senior Project Engineer to join our dynamic Program & Construction Management team in Los...
-
Audit Manager and Senior Leader
4 weeks ago
Long Beach, California, United States Affinity Executive Search Full timeExceptional Career Opportunities for Audit Managers and SeniorsWe are seeking highly skilled Audit Managers and Seniors to join our team at a well-established, highly profitable CPA firm. This is a hybrid role, allowing you to work from both our office and your home with flexible hours.As an Audit Manager or Senior, you will have the opportunity to work with...
-
Senior Project Manager
4 weeks ago
Long Beach, California, United States Balfour Beatty US Full timeJob SummaryBalfour Beatty US is seeking a highly skilled Senior Project Engineer to join our team. As a key member of our project management team, you will be responsible for assisting the Project Manager and Construction Manager with the planning and execution of construction projects.Key ResponsibilitiesAssist in managing project schedules, budgets, and...
-
Senior Manager of Philanthropy
3 weeks ago
Long Beach, California, United States TPIRC Full timeJob Title: Senior Manager, PhilanthropyAbout the Role:The Senior Manager of Philanthropy will play a critical role in developing and executing strategies to secure financial support from individuals, foundations, and corporations. This position involves managing donor and volunteer relationships, organizing fundraising events, overseeing grant writing and...
-
Senior Project Manager
2 weeks ago
Long Beach, California, United States Harris & Associates Full timeHarris & Associates is seeking a highly skilled Senior Project Engineer to join our dynamic Program & Construction Management team in Los Angeles, California.The ideal candidate will have a strong background in construction management, with experience in coordinating complex projects with construction values in excess of $10M.Responsibilities will include...
-
Senior Administrative Coordinator
3 weeks ago
Long Beach, California, United States Beach Front Property Management Full timeWe are seeking a highly organized and proactive Senior Admin Assistant to join our team at Beach Front Property Management, Inc. The ideal candidate will be detail-oriented, possess excellent communication skills, and thrive in a fast-paced environment.Key Responsibilities:Manage executive calendars, scheduling appointments, meetings, and travel arrangements...
-
Senior Accounting Manager
4 weeks ago
Long Beach, California, United States gpac Full timeSenior Accounting ManagerWe are seeking a highly skilled and experienced Senior Accounting Manager to join our dynamic finance team at GPAC, an award-winning search firm specializing in placing quality professionals within multiple industries across the United States since 1990.Key Responsibilities:Tax Management and Strategy:Develop and implement effective...
-
Audit Manager and Senior Leadership Position
2 weeks ago
Long Beach, California, United States Affinity Executive Search Full timeExceptional Career Opportunities for Audit Managers and SeniorsA well-established, highly profitable CPA firm is seeking exceptional Audit Managers and Seniors to join their team in a hybrid work arrangement. This opportunity offers a unique blend of flexibility and stability, with the ability to work from both the office and home with flexible hours. The...
Utilization Management Nurse, Senior
2 months ago
The Facility Compliance Review team at Blue Shield of California 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. In this role, you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care.
Your Responsibilities- Perform 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.
- Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
- Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members in compliance with state, federal, and accreditation requirements.
- Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service, or treatment delays and intervene as clinically appropriate.
- Clearly communicate and collaborate while working effectively and efficiently.
- Review itemizations for coding logic using industry standards as well as CMS guidelines.
- Triage and prioritize cases to meet required turn-around times.
- Identify potential quality of care issues, service, or treatment delays as clinically appropriate.
- Utilize clinical judgment and detailed knowledge of benefit plans to complete review decisions.
- Requires a Bachelor's of Science in Nursing or advanced degree preferred.
- Requires a current California RN License.
- Typically requires a college degree or equivalent experience and minimum 5 years of prior relevant experience.
- Typically requires advanced knowledge of job area typically obtained through advanced education combined with experience. May have practical knowledge of project management.
- Requires strong written and oral communication skills.
- Requires strong analytical and problem-solving skills.
- Active AAPC or ADHIMA coding certification, eg CPC-CIC or COC with procedure coding experience (HCPCS/CPT) preferred.
- Strong attention to detail to include ability to analyze claim data analytics preferred.
- Independent motivation, strong work ethic, and strong computer navigation skills preferred.
- Arbitration experience preferred.
- DRG validation review experience preferred.
