Care Coordination Specialist

7 days ago


Rancho Cordova, California, United States Blue Shield of California Full time
Job Description

At Blue Shield of California, we are seeking a highly skilled Care Coordination Specialist - Utilization Management to join our team.

About the Role

This is an exciting opportunity to work in a dynamic environment where you will play a critical role in ensuring that our members receive high-quality care while also promoting cost-effective healthcare services.

In this position, you will be responsible for conducting thorough clinical reviews of claims to determine medical necessity, coding accuracy, and compliance with medical policies and contracts.

Duties and Responsibilities
  • Perform prospective, concurrent, and retrospective utilization reviews and first-level determination approvals for long-term care members using BSC evidence-based guidelines, policies, and nationally recognized clinical criteria.
  • Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
  • Evaluate discharge planning at levels of care appropriate for members' needs and acuity, determining post-acute needs, including levels of care, durable medical equipment, and post-service needs.
  • Prepare and present cases to the Medical Director for oversight and necessity determination, communicating determinations to providers and/or members in compliance with state, federal, and accreditation requirements.
  • Develop and review member-centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards.
Requirements

We are looking for a qualified individual who possesses a bachelor's degree or equivalent experience and has strong communication and computer navigation skills. Additionally, you must be able to maintain quality and productivity metrics for all casework and maintain a HIPAA-compliant workspace for a telework environment.

Estimated Salary Range

The estimated annual salary for this position is $85,000-$110,000, depending on qualifications and experience.


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