Medical Case Reviewer

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...

Job OverviewThis position is responsible for conducting prospective and retrospective reviews of requests for service authorizations to ensure continuity and coordination of care.Key Responsibilities:Determine compliance with established medical necessity criteria using Milliman and Healthcare Management Guidelines.Redirect members to alternative treatments...

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...

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 OverviewWe are seeking a skilled Nursing Case Manager to join our team at Blue Shield of California.About the RoleIn this role, you will be responsible for coordinating care with specialists, community resources, and healthcare providers to ensure high-quality, cost-effective patient outcomes. Your expertise in nursing and case management will enable you...

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 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.

The Medical Management Specialist-LVN plays a crucial role in promoting and supporting the quality, medical necessity, and cost-effectiveness of care and services at SCAN Health Plan. This position is responsible for ensuring that necessary inpatient and outpatient care and services are rendered to SCAN members at the right time, at the right level of care,...

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...

Job Summary:We are seeking a skilled Nurse Case Manager Senior to oversee patient care coordination in outpatient settings. This role involves developing individualized care plans, collaborating with healthcare professionals, and conducting health assessments to ensure the appropriate management of patient needs.About Us:Blue Shield of California is a...

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 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 SummaryWe are seeking a highly skilled Clinical Case Manager to join our team at Blue Shield of California. As a Clinical Case Manager, you will play a vital role in determining, developing, and implementing plans of care for our members.This is an exciting opportunity to work with a talented team of professionals who are passionate about delivering...

About the RoleWe are seeking a skilled Healthcare Case Manager to join our team at Blue Shield of California.This role requires a current CA RN License and 5+ years of experience in nursing, healthcare or related field.The ideal candidate will have strong clinical documentation skills, independent problem identification and resolution skills, as well as...

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...

Blue Shield of California is seeking a skilled Nurse Case Manager to join our team in the Federal Employee Program (FEP) department.About the RoleThis role involves coordinating care for lower levels of care, including residential treatment, partial hospitalization programs, intensive outpatient programs, and community programs as appropriate.We are looking...

About the RoleWe are seeking a highly skilled and detail-oriented Healthcare Coordinator - Case Management Specialist to join our team. In this role, you will play a vital part in managing the medical/disease management process for members by providing exceptional customer service, coordination of care, and administrative support.ResponsibilitiesConduct...

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...

Job SummaryWe are seeking a highly skilled and compassionate Behavioral Health Case Manager to join our team at Blue Shield of California.About the RoleThis is an exciting opportunity for a dedicated healthcare professional to make a meaningful difference in the lives of our members. As a Behavioral Health Case Manager, you will be responsible for...