Clinical Review Nurse
19 hours ago
The Commercial Post Service Review team at Blue Shield of California is responsible for clinically reviewing claims that are the result of either a preservice or claim denial. As a Senior Clinical Reviewer, you will report to the Manager, Post Service, and perform accurate and timely clinical review of post service claims for the CalPERS population.
The successful candidate will review outpatient post service cases for benefits, medical necessity, coding accuracy, and medical policy compliance, utilizing the Blue Shield of California Medical Policy, Blue Shield of California evidenced-based guidelines, policies, and nationally recognized clinical criteria.
Your WorkIn this role, you will:
- Prepare and submit clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination if needed.
- Communicate determinations to members and providers in compliance with state, federal, and accreditation requirements.
- Ensure proper procedure codes and diagnosis codes are reviewed for submitted claims match the services that were performed.
- Initiate appropriate referrals for members' needs to other departments, such as Case Management, Potential Quality Issues (PQI), etc.
- Triage and prioritize your caseload to meet required regulatory turn-around times.
To be successful in this role, you will require:
- A current CA RN License.
- A Bachelors of Science in Nursing or advanced degree preferred.
- At least 5 years of prior experience in nursing, healthcare, or other related fields.
- Knowledge of the insurance industry and benefit reviews preferred.
- Knowledge of CPT-4, ICD-9, HCPCs, with 1-2 years' experience in coding.
- Knowledge of hospital billing patterns, Charge Master descriptions, and contract language.
- Strong analytical and problem-solving skills.
- Advanced knowledge of job area typically obtained through advanced education combined with experience.
- Experience in MediCare and MediCal, preferred.
Pay Range:
The pay range for this role is: $ 87,230.00 to $ 130,900.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
-
Clinical Review Nurse
4 weeks ago
Rancho Cordova, California, United States Actalent Full timeAbout the RoleWe are seeking a skilled Clinical Review Nurse to join our team at Actalent. As a Clinical Review Nurse, you will play a critical role in ensuring that our clients receive high-quality care and services.Key ResponsibilitiesConduct thorough reviews of medical records to ensure accuracy and completenessCollaborate with healthcare professionals to...
-
Clinical Reviewer
1 day ago
Rancho Cordova, California, United States Blue Shield Of California Full timeAbout the RoleWe are seeking a skilled Clinical Reviewer to join our Appeals and Grievances team at Blue Shield of California. As a key member of our team, you will play a critical role in ensuring that our members receive high-quality care and that our clinical decisions are informed by the latest evidence-based guidelines.Key ResponsibilitiesConduct...
-
Senior Clinical Review Nurse
16 hours ago
Rancho Cordova, California, United States Blue Shield of California Full timeJob SummaryBlue Shield of California is seeking a skilled Senior Clinical Review Nurse to join our Commercial Post Service Review team. As a key member of our team, you will be responsible for clinically reviewing claims that are the result of either a preservice or claim denial.Key ResponsibilitiesPerform accurate and timely clinical review of post service...
-
Clinical Quality Review Manager
1 day ago
Rancho Cordova, California, United States Blue Shield of CA Full timeAbout the RoleThe Clinical Quality Review team at Blue Shield of California is seeking a seasoned leader to oversee the review of potential quality issues that impact our members, providers, and staff. As a key member of our Quality Management and Assurance team, you will work closely with medical directors to identify and address quality concerns, ensuring...
-
Appeals and Grievances Clinical Reviewer
15 hours ago
Rancho Cordova, California, United States Blue Shield of California Full timeAbout the RoleThe Appeals and Grievances team at Blue Shield of California is seeking a skilled RN Senior to join our team. As a Clinical Reviewer, you will play a critical role in ensuring that member appeals and grievances are handled in a timely and accurate manner.Key ResponsibilitiesConduct thorough clinical reviews of member-initiated appeals and...
-
Travel Nurse RN Clinic
2 weeks ago
Rancho Cordova, California, United States Travel Nurses, Inc. Full timeJob Title: Clinic Travel Nurse RNWe are seeking a skilled and experienced Clinic Travel Nurse RN to join our team at Travel Nurses, Inc. This is a 13-week assignment with 36 hours per week, working 12-hour night shifts.Job DescriptionSpecialty: ClinicDiscipline: RNDuration: 13 weeksHours: 36 hours per weekShift: 12 hours, nightsEmployment Type: TravelAs a...
-
Travel Nurse RN Clinic Opportunity
4 weeks ago
Rancho Cordova, California, United States Travel Nurses, Inc. Full timeJob DetailsWe are seeking a skilled Travel Nurse RN Clinic to join our team in Rancho Cordova, California. This 13-week assignment offers a unique opportunity to work in a dynamic environment and provide high-quality patient care.Job RequirementsSpecialty: ClinicDiscipline: RNDuration: 13 weeksHours: 36 hours per weekShift: 12 hours, nightsEmployment Type:...
-
Travel Nurse RN Position
3 weeks ago
Rancho Cordova, California, United States Titan Nurse Staffing Full timeJob Title: Travel Nurse RN ClinicTitan Nurse Staffing is seeking a skilled travel nurse RN for a Clinic position in California.Job Details:Specialty: ClinicDiscipline: RNDuration: 13 weeks, 36 hours per weekShift: 12 hours, nightsEmployment Type: TravelWe offer our clients the best in traveling medical professionals. Our success relies on your success, which...
-
Travel Nurse RN Position
4 weeks ago
Rancho Cordova, California, United States Titan Nurse Staffing Full timeJob DetailsTitan Nurse Staffing is seeking a skilled travel nurse RN for a Clinic position in California.Job RequirementsSpecialty: ClinicDiscipline: RNShift: 12 hours, nightsEmployment Type: TravelWe are looking for a qualified healthcare professional to fill this position. The ideal candidate will have a minimum of 2 years of experience in a Clinic...
-
Travel Nurse RN Clinic
2 days ago
Rancho Cordova, California, United States Cross Country Nurses Full timeTravel Nurse RN Clinic Job DescriptionCross Country Nurses is seeking a skilled travel nurse RN clinic professional to fill a challenging and rewarding travel nursing position in Rancho Cordova, California.Job RequirementsSpecialty: ClinicDiscipline: RNDuration: 13 weeksShift: 12 hoursEmployment Type: TravelAs a registered nurse clinic, you will provide...
-
Travel Nurse RN Clinic
3 weeks ago
Rancho Cordova, California, United States Travel Nurses, Inc. Full timeJob OpportunityTravel Nurses, Inc. is seeking a skilled travel nurse for a clinic position in Rancho Cordova, California.Job DetailsSpecialty: ClinicDiscipline: RNDuration: 13 weeksHours: 36 hours per weekShift: 12 hours, nightsEmployment Type: TravelWe are looking for a dedicated and flexible travel nurse to join our team for an immediate opening in Rancho...
-
Clinical Services Coordinator
12 hours ago
Rancho Cordova, California, United States Blue Shield of California Full timeYour RoleThe Clinical Services team is a key component of Blue Shield of California's operations. As a Clinical Services Coordinator, you will be responsible for processing phone and faxed requests for Continuity of Care, Access to Care for both commercial and Medi-Cal membership. This role may also require Peer or Peer provider support and other duties...
-
Travel Nurse RN Clinic
2 weeks ago
Rancho Cordova, California, United States Travel Nurses, Inc. Full timeJob OpportunityTravel Nurses, Inc. is seeking a skilled travel nurse RN for a clinic position in Rancho Cordova, California.Job DetailsSpecialty: ClinicDiscipline: RNDuration: 13 weeksHours: 36 hours per weekShift: 12 hours, nightsEmployment Type: TravelWe are looking for a dedicated and flexible RN to join our team for an immediate opening in Rancho...
-
Travel Nurse RN Clinic
3 weeks ago
Rancho Cordova, California, United States Travel Nurses, Inc. Full timeJob OpportunityTravel Nurses, Inc. is seeking a skilled travel nurse RN for a clinic position in Rancho Cordova, California.Job DetailsSpecialty: ClinicDiscipline: RNDuration: 13 weeksHours: 36 hours per weekShift: 12 hours, nightsEmployment Type: TravelWe are looking for a dedicated Clinic RN for an immediate opening in Rancho Cordova, California. The ideal...
-
Travel Nurse RN Clinic Position
4 weeks ago
Rancho Cordova, California, United States Travel Nurses, Inc. Full timeTravel Nurse RN Clinic Job OpportunityWe are seeking a skilled Travel Nurse RN Clinic to join our team at a top-rated healthcare facility in Rancho Cordova, California. As a Travel Nurse RN Clinic, you will have the opportunity to work in a dynamic and fast-paced environment, providing high-quality patient care and collaborating with a talented team of...
-
Clinical Technician
1 day ago
Rancho Cordova, California, United States Akua Behavioral Health Full timeJob Title: Clinical TechnicianAkua Behavioral Health is seeking a skilled Clinical Technician to join our team. As a Clinical Technician, you will play a vital role in supporting our clients in their recovery journey.Key Responsibilities:Provide support to clients during their shift, ensuring their safety and well-being.Conduct orientation to new clients,...
-
Travel Nurse RN Position
3 weeks ago
Rancho Cordova, California, United States Jackson Nurse Professionals Full timeTravel Nurse RN Long Term Acute Care Job OpportunityJackson Nurse Professionals is seeking a skilled travel nurse RN to fill a Long Term Acute Care position in Rancho Cordova, California.Job DetailsSpecialty: Long Term Acute CareDiscipline: RNDuration: 13 weeksShift: FlexibleEmployment Type: TravelThe pay package is based on 12 hour shifts and 36 hours per...
-
Travel Registered Nurse Clinic Opportunity
2 weeks ago
Rancho Cordova, California, United States Anders Group Full timeTravel Registered Nurse Clinic Job in Rancho Cordova, CAAnders Group is a top-rated healthcare staffing agency offering a fulfilling travel registered nurse clinic job in Rancho Cordova, CA. As a travel nurse, you will have the opportunity to work in a dynamic and challenging environment, providing high-quality patient care and developing your clinical...
-
Travel Nurse RN Clinic Opportunity
1 month ago
Rancho Cordova, California, United States Travel Nurses, Inc. Full timeTravel Nurse RN Clinic Job DescriptionWe are seeking a skilled and experienced RN Clinic to join our team at Travel Nurses, Inc. for a 13-week travel nursing assignment in Rancho Cordova, California.Job RequirementsSpecialty: ClinicDiscipline: RNDuration: 13 weeksShift: 12 hours, nightsEmployment Type: TravelAs a travel nurse with Travel Nurses, Inc., you...
-
Travel Nurse RN Clinic Opportunity
2 weeks ago
Rancho Cordova, California, United States Nationwide Therapy Group Full timeJob Title: Travel Nurse RN ClinicNationwide Therapy Group is seeking a skilled travel nurse RN Clinic to join our team in Rancho Cordova, California.Job Description & RequirementsSpecialty: ClinicDiscipline: RNDuration: 13 weeksHours: 36 hours per weekShift: 12 hours, nightsEmployment Type: TravelWe offer a competitive pay package, including a tax-free...