Medical Policy Utilization Management Nurse

Your RoleThe Medical Management team at Blue Shield of California is dedicated to ensuring that our organization is at the forefront of medical, medication, and payment policy to accelerate the emergence of a value-based healthcare system in California. As the Medical Director, Utilization Management (CalPERS), you will report to the Vice President, Medical...

About the RoleWe are seeking a highly skilled Medical Director, Utilization Management to join our team at Blue Shield of California. As a key member of our Medical Management department, you will play a critical role in ensuring our members receive the right level of care, at the right time, and at the right cost.Key ResponsibilitiesReview and make...

Job SummaryBlue Shield of California is seeking a highly skilled Medical Director, Utilization Management to join our team. As a key member of our Medical Management department, you will play a critical role in ensuring our Medi-Cal members receive the right level of care, at the right time, and at the right cost.The ideal candidate will have a strong...

Job SummaryThe Medical Director, Utilization Management will serve as a key member of the Blue Shield of California Promise Health Plan's utilization management review team. This role reports to the VP, Medical Management or their designee.Key ResponsibilitiesReview and make determinations regarding all member and provider requests for service, including...

Job SummaryWe are seeking a highly skilled Medical Director, Utilization Management to join our team at Blue Shield of California. The successful candidate will be responsible for leading our utilization management efforts, ensuring that our members receive high-quality, cost-effective care.Key ResponsibilitiesDevelop and implement utilization management...

Job 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...

Job SummaryThe Senior Utilization Management Nurse will be responsible for reviewing inpatient stays for our members under nationally recognized levels of care guidelines. This role requires a strong clinical background and excellent analytical skills to determine medical necessity of admissions, appropriate length of stay, and level of care.Key...

Job SummaryThe Senior Utilization Management Nurse will play a key role in ensuring that members receive high-quality, cost-effective care. This position will be responsible for performing first-level determination approvals for members using BSC evidenced-based guidelines, policies, and nationally recognized clinical criteria.Key ResponsibilitiesPerform...

About the RoleThe Utilization Management Nurse, Senior will play a critical role in ensuring that members receive high-quality, cost-effective care. This position will be responsible for performing first-level determination approvals for members using evidence-based guidelines, policies, and nationally recognized clinical criteria.Key ResponsibilitiesPerform...

About the RoleThe Utilization Management Nurse, Senior will play a critical role in ensuring the quality and cost-effectiveness of healthcare services for our members.Key ResponsibilitiesConduct prospective, concurrent, and retrospective utilization reviews to determine medical necessity and ensure compliance with nationally recognized clinical...

About the RoleThe Medical Director, Utilization Management plays a critical role in ensuring the delivery of high-quality, cost-effective healthcare services to our members. As a key member of the Blue Shield of California Medical Management team, you will be responsible for reviewing and making determinations regarding member and provider requests for...

Your RoleAs a Senior Utilization Management Nurse at Blue Shield of California, you will play a critical role in ensuring the quality and cost-effectiveness of healthcare services for our members.Key ResponsibilitiesConduct thorough reviews of inpatient stays to determine medical necessity and ensure compliance with nationally recognized...

Your RoleAs a Utilization Management Nurse, you will play a critical role in ensuring that our members receive the highest quality care while minimizing unnecessary costs. You will be responsible for reviewing inpatient stays and applying nationally recognized levels of care guidelines to determine medical necessity.Your WorkConduct thorough reviews of...

Job Summary:We are seeking a highly skilled Medical Policy Supervisor to join our team at Prime Therapeutics. As a key member of our operations team, you will be responsible for leading a team of claims professionals and ensuring the efficient processing of medical claims.Key Responsibilities:Lead a team of claims professionals to achieve high levels of...

Your RoleAs a key member of the Utilization Management team at Blue Shield of California, the Director, Medicare & Medi-Cal Utilization Management plays a critical role in delivering and collaborating on all aspects of utilization management and care coordination for our Medicare and Medi-Cal membership.This individual will lead the development of UM...

About the RoleThe Director of Medicare and Medi-Cal Utilization Management will play a critical role in the success of Blue Shield of California and the Utilization Management department in realizing its goals and objectives.Key ResponsibilitiesDevelop and implement utilization management strategies to ensure timely and cost-effective care for patients.Lead...

SBM Management is seeking a Custodial Operations Manager to oversee activities within assigned programs. The successful candidate will be responsible for ensuring safe work practices and procedures are implemented and adhered to.Key Responsibilities: Oversee activities within assigned programs Ensure safe work practices and procedures are implemented and...

Your RoleThe Medical Director, Operations (Behavioral Health) will report to the Senior Medical Director, Behavioral Health at Blue Shield of California. In this role, you will have core responsibilities in the areas of psychiatric inpatient concurrent review, pre- and post-service utilization review, and collaboration with Nurse Care Managers.Key...

Job SummaryChild Action, Inc. is seeking a highly skilled Legislative Analyst to join our team. As a key member of our Government Affairs Department, you will play a critical role in shaping our legislative strategy and advocating for the interests of our organization and the families we serve.Key ResponsibilitiesConduct thorough research on legislative...

Job SummaryWe are seeking a highly skilled and experienced Case Manager to join our team at Blue Shield of California. As a Case Manager, you will play a critical role in coordinating care for our members, ensuring they receive the highest quality of care while minimizing costs.Key ResponsibilitiesCoordinate care for members, including Skilled Nursing...