RanchoCordovaRecruiter Since 2001
the smart solution for Rancho Cordova jobs

RN / Case Management / California / Permanent / Utilization Management

Company: Blue Shield of California
Location: Rancho Cordova
Posted on: February 19, 2021

Job Description:

Utilization and Medical Review: Ensures accurate and timely prior authorization of designated healthcare services. Utilization Management Nurse:Performs prospective, 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 FEP. Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions. Essential Responsibilities: *Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance. *Ensures diagnosis matches ICD10 codes. *Solicits support from SME's, leads and managers as appropriate.*Participates in huddles/ team meetings. *Triages and prioritizes cases to meet required turn-around times.*Expedites access to appropriate care for members with urgent needs.*Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determination. *Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements. *Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards. *Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate. *Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary. *Identifies potential over-payments: - CISD reviews claims for Medical Necessity for Providers - FCR reviews claim for Facility Compliance Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments. *Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives. *Other duties as assigned

Keywords: Blue Shield of California, Rancho Cordova , RN / Case Management / California / Permanent / Utilization Management, Executive , Rancho Cordova, California

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category
within


Other Executive Jobs


Infrastructure Project Manager
Description: Provide Project Management PM services to support several telecommunications infrastructure projects to protect the Transmission
Company: MatchPoint Solutions
Location: San Ramon
Posted on: 02/27/2021

Client Engagement Manager / Marketing Consultant
Description: Alaniz is a fast growing digital marketing agency located in Marin County. We have a tight-knit team of marketing professionals and we have big plans for where we want to take our agency. We are currently (more...)
Company: ALANIZ MARKETING
Location: San Rafael
Posted on: 02/27/2021

Manager - Business Development
Description: Job Description - Manager - Business Development 20000730 Job Description Manager - Business Development - 20000730 Offer Title : Manager - Business Development About Company HydroChemPSC is the (more...)
Company: CTI Education Group
Location: San Ramon
Posted on: 02/27/2021


Merchandise Ops Leader (Department Manager)
Description: Category: Stores br Location: 2005 Crow Canyon Pl, San Ramon , CA--94583 br Schedule: Full time C ome work at a place where innovation and teamwork come together to support the most exciting missions (more...)
Company: Petco Animal Supplies, Inc.
Location: San Ramon
Posted on: 02/27/2021

Global Liquidity Product Manager, Cash Management
Description: Global Liquidity Product Manager, Cash Management At Bank of the West, our people are having a positive impact on the world. We're investing where we feel we can make the most impact, like advancing diversity (more...)
Company: BNP Paribas
Location: San Ramon
Posted on: 02/27/2021

Procurement Manager
Description: EO Products is a company with one mission and two brands: to create--healthy--personal care products that--nurture--the people who use them,--respect--the people who make them, and--honor--the planet (more...)
Company: EO Products
Location: San Rafael
Posted on: 02/27/2021

Assistant Salon Manager - Riverpoint Marketplace
Description: Assistant Salon ManagerGot shears and a winning attitude Have a yearning to earn and a desire to support other stylists Then let's talk Maybe you're a stylist who wants more responsibility,
Company: Great Clips
Location: West Sacramento
Posted on: 02/27/2021

Associate Director/Director of Clinical Pharmacology
Description: Associate Director / Director, Clinical Pharmacology BioMarin is the world leader in delivering therapeutics that provide meaningful advances to patients who live with serious and life-threatening rare (more...)
Company: BIOMARIN
Location: San Rafael
Posted on: 02/27/2021

Product Manager - Ecosystem
Description: Job description:The Product Manager - Ecosystem is a key member accelerating product innovation across GEHC product lines by providing a continuous relationship with market-ready third parties to drive (more...)
Company: GE Healthcare
Location: San Ramon
Posted on: 02/27/2021

Product Strategy & Execution Manager, Cash Management
Description: At Bank of the West, our people are having a positive impact on the world. We're investing where we feel we can make the most impact, like advancing diversity and women entrepreneurship programs, financing (more...)
Company: CTI Education Group
Location: San Ramon
Posted on: 02/27/2021

Log In or Create An Account

Get the latest California jobs by following @recnetCA on Twitter!

Rancho Cordova RSS job feeds