Senior Clinical Utilization Review Nurse

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 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...

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.

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...

**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 Title: Senior Clinical Nurse Case Manager - Federal Employee ProgramOverview:The Blue Shield of California team seeks an experienced and skilled Senior Clinical Nurse Case Manager to join our Federal Employee Program. As a Senior Clinical Nurse Case Manager, you will be responsible for conducting comprehensive assessments, developing care plans, and...

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 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...

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 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...

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...

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 RoleWe are seeking a highly skilled Senior Case Management Nurse to join our team at Blue Shield of California. This role will play a crucial part in supporting patients' health and wellness in an outpatient setting.The successful candidate will have experience in developing individualized care plans, coordinating with healthcare providers, and...

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 SCANSCAN is a leading not-for-profit organization dedicated to improving the lives of older adults in the United States. With over 45 years of experience, SCAN has established itself as a trusted expert in senior healthcare.The OpportunityWe are seeking a highly skilled Senior Medical Policy Analyst to join our team. As a key member of our Medical...

Job OverviewThe Blue Shield of California is seeking a highly skilled Healthcare Utilization Manager to join our team. In this role, you will play a critical part in ensuring that our members receive high-quality care while also managing costs.Job SummaryWe are looking for an experienced and detail-oriented professional with excellent communication skills...

Company Overview:Blue Shield of California is a leading healthcare organization that delivers best-in-class clinical quality analytics and informatics to enable high-quality and affordable member-centered care.About the Role:We are seeking an experienced Data Analyst - Clinical Quality Senior to join our team. This role will provide data, analytic, and...

Company Overview:Senior Resource Group has been a pioneer in the development and operation of senior living communities across the USA for over 35 years. Our dedication to innovative community design, exceptional service, and outstanding care has earned us numerous awards.Job Description:We are seeking a skilled Regional Nurse to join our growing clinical...

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...

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...