Clinical Review Specialist

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...

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...

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 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: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...

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...

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...

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...

Job Title: PICU Clinical Nurse SpecialistJob Summary:Fifth Commandment Healthcare Staffing, LLC is seeking an experienced PICU Clinical Nurse Specialist to join our team. As a PICU Clinical Nurse Specialist, you will be responsible for providing high-quality patient care and leading the nursing team in the Pediatric Intensive Care Unit.Key Responsibilities:-...

Job SummaryWe are seeking a skilled Clinical Support Specialist to join our team at Pacific Neuropsychiatric Specialists Inc.About the RoleThis is a full-time position that offers a competitive compensation package including medical, dental, and vision insurance, paid time off, and hourly rate based on skill, experience, and tenure.Key...

About TotalMed StaffingTotalMed is a leading healthcare staffing agency with a mission to provide top-notch clinical professionals to facilities nationwide.We are dedicated to igniting purpose in healthcare by matching skilled caregivers with the right organizations to ensure exceptional patient outcomes.Job OverviewTotalMed is seeking an experienced...

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...

Job SummaryThe Clinical Support Specialist will perform all support functions in the Radiology department, including transporting patients, clerical duties, and reception work. This role requires strong communication skills to interact effectively with others and demonstrate problem-solving ability.About MemorialCareMemorialCare is a nonprofit integrated...

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 SummaryWe are seeking a highly experienced Clinical Diabetes Specialist to join our team at Sequel Medical Technology. In this role, you will be responsible for delivering exceptional clinical education and product training to people with diabetes and healthcare providers, driving the adoption and consistent use of our innovative insulin pump...

Blue Shield of California seeks a Pharmacy Support Specialist to join our team.Estimated Salary: $60,000 - $80,000 per yearAbout the RoleIn this role, you will be part of our Pharmacy Prior Authorization team, providing efficient and accurate responses to external customers and internal team members for all outpatient pharmacy benefit inquiries.You will...

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...

At GenWealth, Inc., we're seeking a seasoned Tax Strategist Specialist to lead our tax preparation team. This role requires expertise in conducting end-to-end review and preparation of business and personal tax returns for high-income-earning individuals.About the Role:We're looking for a highly skilled Tax Professional with a minimum 3 years of experience...

As a key member of the MemorialCare Health System team, you will play a vital role in delivering exceptional patient care as a RN, Clinical Nurse Specialist. Located in Long Beach, this full-time position offers a competitive salary and benefits package.Responsibilities include providing clinical expertise to direct the nursing process, mentoring and...