- Elevance Health (Costa Mesa, CA)
- …and abuse prevention and control. + Review and conducts analysis of claims and medical records prior to payment. Researches new healthcare-related questions ... **Clinical Fraud Investigator II - Registered Nurse and CPC - Calrelon...Integrity, is determined to recover, eliminate and prevent unnecessary medical -expense spending. The **Clinical Fraud Investigator II** is responsible… more
- CVS Health (Sacramento, CA)
- …however, it is subject to change based on business needs.** The RN Case Manager is responsible for telephonically assessing, planning, implementing, and coordinating ... all case management activities with members to evaluate the medical needs of the member and to help facilitate...- Through the use of clinical tools and information/data review , conducts an evaluation of member's needs and benefit… more
- LA Care Health Plan (Los Angeles, CA)
- …case management referrals (5%) Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, ... requirements for health plan compliance with UM or CM. Licenses/Certifications Required Registered Nurse ( RN ) - Active, current and unrestricted… more
- Veterans Affairs, Veterans Health Administration (San Diego, CA)
- …State Veterans Home Liaison, Administrative Assistant, Administrative staff for review of eligibility, authorizations and scheduling etc., Registered ... refer to Required Documents below. The Jennifer Moreno DVA Medical Center in beautiful San Diego, California is looking...level degree in Nursing may have opportunity to become registered as a nurse with a state… more
- LA Care Health Plan (Los Angeles, CA)
- …of Microsoft Office suite, including Word, Excel and PowerPoint. Licenses/Certifications Required Registered Nurse ( RN ) - Active, current and unrestricted ... Payment Integrity Nurse Coder RN III Job Category: Clinical Department: Claims...policies within the claim adjudication process through medical record review for Payment Integrity and… more
- Stanford Health Care (Palo Alto, CA)
- …180 Days or + CCDS - Cert Clinical Document Spec required within 180 Days + RN - Registered Nurse - State Licensure And/Or Compact State Licensure preferred ... while identifying instances of overpayments and underpayments. Proficiency in healthcare claims analysis, including the ability to review , interpret, and… more
- Sedgwick (Sacramento, CA)
- …providers to support the claim request and documents decision rationale. + Completes medical review of all claims by reviewing medical documentation ... clinical evaluations on claims that require additional review based on medical condition, client requirement,... management of claims including comprehension of medical terminology and substantiating claim decisions. **ADDITIONAL… more
- Highmark Health (Sacramento, CA)
- …+ 1-3 years of experience in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder or related ... rejection and the proper action to complete the retrospective claim review with the goal of proper...Review process includes a review of medical documentation, itemized bills, and claims data… more
- Sutter Health (Oakland, CA)
- …an accredited school of nursing Required + BSN Preferred **CERTIFICATION & LICENSURE** + RN - Registered Nurse of California Required + Certified Case Manager ... position works in collaboration with the Physician, Utilization Manager, Medical Social Worker and bedside RN to...services, third party payers and review agencies, claims and finance departments, Medical Directors, and… more
- Ventura County (Ventura, CA)
- …patient-centered care. Under general direction, the Senior Medical Management Nurse is responsible for performing utilization review , case management, and ... the link below: CNA_MOA_2023-2028.pdf (ventura.org) (https://vcportal.ventura.org/CEO/HR/MOA/docs/CNA\_MOA\_2023-2028.pdf) PAYROLL TITLE: Senior Registered Nurse - Ambulatory Care DISTINGUISHING CHARACTERISTICS:… more