- Dialysis Clinic, Inc. (Sacramento, CA)
- …5,000 talented and caring employees serving across the United States, DCI provides care to nearly 15,000 patients on dialysis and 3,500 patients with chronic kidney ... staff, contributes toward the goal of providing excellent patient care . Our staff has helped DCI achieve the lowest...information for assigned patients by staying in contact with clinical staff and social workers, calling insurance companies and… more
- Alameda Health System (San Leandro, CA)
- Care Management Clinical Appeals Specialist + San Leandro, CA + Finance + Patient Financial Svcs - Facil + Full Time - Day + Business Professional & IT + ... and executes the appeal process for all AHS facilities clinical appeals and third party audits. **DUTIES...documented on all patient medical records. 6. Coordinates with Care Management team when cases do not… more
- LA Care Health Plan (Los Angeles, CA)
- …Skills Required: Knowledge of state, federal and regulatory requirements in Appeals / Care /Case/Utilization Management /Quality. Strong verbal and written ... in Nursing Experience Required: Minimum of 8 years of acute/ clinical care experience. Minimum of 2 years...in a lead/supervisory experience. Equivalency: Completion of the LA Care Management Certificate Training Program may substitute… more
- LA Care Health Plan (Los Angeles, CA)
- …in a consistent and accurate manner. This position will focus on quality review of non- clinical grievance and appeals cases for all line of business (LOB) to ... Customer Solution Center Appeals and Grievances Quality Auditing Specialist II Job...$87,342.00 (Mid.) - $107,498.00 (Max.) Established in 1997, LA Care Health Plan is an independent public agency created… more
- Magellan Health Services (San Diego, CA)
- Coordinates appeals process as assigned, attends to risk management issues associated with case management and processes appeal requests. In some cases may ... day compliance of appeal decision time frames. + Reviews clinical and medical records for completeness and determines administrative...medical necessity reviews. + Enters all data related to appeals and case reviews into a database. + Prepares… more
- Centene Corporation (Sacramento, CA)
- …be the one who changes everything for our 28 million members as a clinical professional on our Medical Management /Health Services team. Centene is a diversified, ... or equivalent. Associate's degree preferred. 2+ years grievance or appeals , claims or related managed care experience....grievance or appeals , claims or related managed care experience. Strong oral, written, and problem solving skills.Pay… more
- Providence (Santa Rosa, CA)
- **Description** **Providence is calling a Claims Appeals Representative who will work remotely within our footprint states, AK, CA, OR, WA, TX, NM, or MT.** The ... Appeal Representative position is responsible for day-to-day review, coordination and management of technical denials requiring background and understanding from a… more
- Humana (Sacramento, CA)
- …ABMS Medical Specialty + Excellent communication skills + 5 years of established clinical experience + Knowledge of the managed care industry including Medicare, ... Medical Director relies on medical background and reviews health claims and preservice appeals . The Corporate Medical Director works on problems of diverse scope and… more
- LA Care Health Plan (Los Angeles, CA)
- …and motivating direct-reports. Duties Responsible for internal health plan operations in care management , utilization management , and managed long-term ... Clinical Operations Executive Job Category: Management /Executive...net required to achieve that purpose. Job Summary The Clinical Operations Executive (COE) of LA Care … more
- Evolent Health (Sacramento, CA)
- …for the mission. Stay for the culture. **What You'll Be Doing:** As a Physician Clinical Reviewer, Interventional Pain Management , you will be a key member of ... You Will Be Doing:** + Serve as the Physician Clinical Reviewer for Interventional Pain Management , reviewing...National Committee for Quality Assurance (NCQA) guidelines. + Provides clinical rationale for standard and expedited appeals .… more
- LA Care Health Plan (Los Angeles, CA)
- …multiple departments throughout LAC including but not limited to QI, Pharmacy, Care Management , Utilization Management , Risk Adjustment, Products, Customer ... Clinical Quality Program Manager II (CAHPS) Job Category:...$115,509.00 (Mid.) - $142,166.00 (Max.) Established in 1997, LA Care Health Plan is an independent public agency created… more
- Prime Healthcare (Ontario, CA)
- …Responsibilities The Corporate Director of Clinical Utilization Management (UM) ... to provide guidance on complex Authorizations, Referrals, Denials and Appeals . + Integrates and coordinates services using continuous quality...+ A minimum of seven (7) years' experience in Clinical Utilization Review or Case Management with… more
- LA Care Health Plan (Los Angeles, CA)
- Supervisor, Care Management Coordinator Job Category: Clinical Department: Care Management Location: Los Angeles, CA, US, 90017 Position Type: Full ... Previous experience in Managed Care preferably in Customer Service, Care Management , Appeals and Grievances and/or Claims. Participated in a 2-year… more
- Evolent Health (Sacramento, CA)
- …providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals . + Utilizes medical/ ... or subspecialty, must also have that BC)- **Required** + Strong clinical , management , communication, and organizational skills- **Required** + Energetic… more
- LA Care Health Plan (Los Angeles, CA)
- …on call coverage. Perform daily care management functions including care team rounds. Review of appeals , grievances and provider disputes. Provide ... Medical Director, Medical Management Job Category: Clinical Department: Utilization...others to ensure that 1) all various day-to-day LA Care clinical operations are performed in a… more
- Highland General Hospital (Oakland, CA)
- …Responsible for the recruitment, orientation, evaluation, counseling and disciplinary action of care management clinical and administrative staff. + ... Performs daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and Interrater Reliability).… more
- Highland General Hospital (Oakland, CA)
- …for the recruitment, orientation, evaluation, counseling and disciplinary action of care management clinical and administrative staff. -Responsible ... daily clinical rounds and monthly audit of charts on care management activities (utilization review, discharge planning and Interrater Reliability).… more
- Elevance Health (Walnut Creek, CA)
- …(formerly IngenioRx) leverages the power of new technologies and a strong, clinical -first lens, to deliver member-centered, lasting pharmacy care . The ** ... clinical programs such as DUR, DIS, and formulary management . **How you will make an impact:** + Maintain...BA/BS in Pharmacy. Minimum of 2 years of managed care pharmacy (PBM) experience or residency in lieu of… more
- City and County of San Francisco (San Francisco, CA)
- …Health SF, and California Advancing and Innovating Medi-Cal (CalAIM) and their impacts on clinical care + Collaborates with the Director of Managed Care ... Care division which oversees the Office of Coordinated Care (OCC), Utilization Management (UM), and Quality...after 10/1/2023 The role will be 10-30% dedicated to clinical responsibilities with the remaining 70-90% dedicated to Deputy… more
- Sharp HealthCare (San Diego, CA)
- …is requesting verification. + Plan of care Works collaboratively with the Hospitalist Care Team and Care Management staff to ensure smooth transitions ... skilled level of care . Makes appropriate referral to Medical Groups' Care Management programs.Communicates with the appropriate Quality Management … more
