Top 533 Remote healthcare claims Jobs in California

Utilization Management and Discharge Planning RN
Santa Clara Family Health Plan —San Jose, CA
- $100,968 - $151,451 a year
- Temporary
- Hybrid work
- Nursing
- Skilled nursing facility
- RN License
- Wellness program
- Health insurance
Quick Apply
5d
VP, Healthcare Revenue Cycle, Enterprise Apps, & Data
KORE1 Technologies —Irvine, CA
- $90 - $135 an hour
- Urgently hiring
- Hybrid work
- Computer Science
- System design
- Bachelor's degree
- Health insurance
- Dental insurance
Quick Apply
3d
Contract Administrator
Open Door Community Health Centers —Sacramento, CA
- $81,153.60 - $94,212.80 a year
- Full-time
- Spanish
- Mid-level
- Analysis skills
- Health insurance
Quick Apply
Claim Specialist - Property Field Inspection
State Farm Mutual Automobile Insurance Company —Santa Monica, CA
- $64,965.62 - $111,595.00 a year
- Overtime
- Mid-level
- Residential
- Analysis skills
- Paid holidays
- Health insurance
Supervisor, Epic Enrollment and Benefits (Tapestry) Applications (Remote Considered) )- 26-68
PriMed Management Consulting Services, Inc. —Stockton, CA
- $123,400 - $165,500 a year
- Full-time
- Remote
- 5 years
- HIPAA
- Master's degree
Quick Apply
5d
Revenue Cycle Analyst (Remote)
Cedars-Sinai —Los Angeles, CA
- $77,022.40 - $119,392.00 a year
- 8 hour shift
- Remote
- Mid-level
- Finance
- High school diploma or GED
- Paid time off
- 403(b)
Claims Examiner (Remote/Hybrid work available)
Imperial Management Administrators Services Inc —Pasadena, CA
- $22 - $30 an hour
- Full-time
- Hybrid work
- Research
- Mid-level
- In-person
Quick Apply
Claims Resolution Specialist
Integrated Pain Management Medical Group, Inc. —Walnut Creek, CA
- $28 - $35 an hour
- Full-time
- HIPAA
- Research
- Mid-level
- Paid holidays
- Health insurance
Quick Apply
11d
Billing Support Specialist II (Remote)
Rula —Los Angeles, CA
- $62,985 - $70,395 a year
- Full-time
- Remote
- Mid-level
- 1 year
- Commercial
- Paid parental leave
- Health savings account
13d
Sr. Denial Specialist (Remote)
Stanford Health Care —Sacramento, CA
- $38.91 - $43.82 an hour
- Full-time
- Remote
- 3 years
- High school diploma or GED
- Mentoring
13d
Supervisor, Epic Enrollment and Benefits (Tapestry) Applications (Remote Considered) )- 26-68
PriMed Management Consulting Services, Inc. —Sacramento, CA
- $123,400 - $165,500 a year
- Full-time
- Remote
- 5 years
- HIPAA
- Master's degree
Quick Apply
5d
Supervisor, Epic Enrollment and Benefits (Tapestry) Applications (Remote Considered) )- 26-68
PriMed Management Consulting Services, Inc. —San Ramon, CA
- $123,400 - $165,500 a year
- Full-time
- Remote
- 5 years
- HIPAA
- Master's degree
Quick Apply
5d
Claims Auditor, Managed Care (remote)
Cedars-Sinai —Los Angeles, CA
- $40.16 - $62.25 an hour
- 8 hour shift
- Remote
- 5 years
- Finance
- Bachelor's degree
Healthcare Data Analytics Consultant - CTH - Remote
Gallagher Benefit Services —Glendale, CA
- $74,500 - $145,500 a year
- Remote
- Mid-level
- Analysis skills
- Presentation skills
3d
Healthcare Economics Consultant - Remote
UnitedHealthcare —Cypress, CA
- $72,800 - $130,000 a year
- Full-time
- Remote
- Pass drug screening
- Mid-level
- 3 years
5d
Patient Services Representative I - Remote - Nationwide
Vituity —Sacramento, CA
- $17.12 - $19.04 an hour
- Overtime
- Remote
- Spanish
- Basic math
- Windows
- Profit sharing
- Wellness program
Facility Outpatient Surgical and Claims Edit Auditor (Remote)
Cedars-Sinai —Los Angeles, CA
- $44.98 - $71.97 an hour
- 8 hour shift
- Remote
- Surgery
- Mid-level
- 3 years
- Dental insurance
- 403(b)
Client Services Operations Analyst (Multi-Specialties) - Remote - Nationwide
Vituity —Sacramento, CA
- $24.48 - $30.36 an hour
- Full-time
- Remote
- Microsoft Excel
- Microsoft Outlook
- Medical office experience
- Profit sharing
- Wellness program
Healthcare Revenue Cycle Billing Specialist II (SNF)
Wipfli —Irvine, CA
- $23 - $30 an hour
- Remote
- Microsoft Excel
- Microsoft Outlook
- HIPAA
- Health savings account
- AD&D insurance
12d
Sr. Clinical Denials Prevention Analyst (Remote)
Stanford Health Care —Sacramento, CA
- $66.52 - $88.14 an hour
- Full-time
- Remote
- Nursing
- RN License
- Bachelor of Science in Nursing
13d

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Utilization Management and Discharge Planning RN

Santa Clara Family Health Plan -
San Jose, CA

Quick Apply

Job Details

Temporary
$100,968 - $151,451 a year
5 days ago

Benefits

Wellness program
Health insurance
On-site gym
Dental insurance
401(k)
Flexible spending account
Tuition reimbursement
Paid time off
Employee assistance program
Vision insurance
401(k) matching
Life insurance
Referral program
Retirement plan

Qualifications

Medicare
Utilization review
Managed care
RN License
Pre-authorization review for utilization management
Case management
Utilization management
Centers for Medicare and Medicaid Services (CMS)
Healthcare compliance

Full Job Description

About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:

The Utilization Management and Discharge Planning Nurse performs clinical review in accordance with applicable regulatory and professional standards for Organization Determination Requests using clinical experience and skills in a collaborative process to assess, plan, implement, coordinate and evaluate options to ensure appropriate utilization of member healthcare services and benefits for all lines-of-business in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

Day to Day:

Conduct clinical review to ensure effective and appropriate utilization of benefits and services for prospective, concurrent and retrospective/claims review organization determination authorization requests within regulatory turnaround requirements for all SCFHP lines of business.
Complete authorization reviews by applying the appropriate clinical criteria/guidelines, policy, procedures and clinical judgment to render coverage determinations.
Document pre-admission status, including living arrangements, physical and mental function, social support, durable medical equipment (DME), and other services received.
Draft appropriate notification letters such as approval, denial, delay and modify notifications to providers and members and language threshold following regulatory requirements..
Perform onsite concurrent review activities, as needed in the home, facility or community setting. For Long Term Care UR RN: Conduct regularly scheduled on-site visits to contracted skilled nursing facilities to follow up on re-admissions, confirm member census, conduct member assessments and provide on-site utilization and concurrent review.
Review and monitor hospital or nursing facility census and internal reports to track, reconcile and update discrepancies in member case files. For Long Term UR RN: Monitor and oversee re-admission and transfer prevention strategy.
Facilitate and coordinate communication related to post discharge with member interdisciplinary care team (ICT) including physicians, specialists, public services, community agencies and vendors to ensure care plan development and coordination of benefits and services.
Apply the use of clinical judgment to identify and coordinate referrals to appropriate departments or programs for member identified continuity of care needs, such as Case Management, Behavioral Health, Managed Long Term Services and Supports (MLTSS), community resources, Pharmacy and Quality.
Proactively and collaboratively interface with external case management staff including delegates to facilitate discharge planning and care transitions.
Maintain adherence with Model of Care of CMC, LTSS and DHCS regulatory requirements.

About You:

Active California Board of Nursing License (RN) without restriction.
Minimum one year of licensed related health care experience.
Knowledge of managed care principles and practices with emphasis in Utilization Management and/or Case Management.
Knowledge of MediCal and/or Medicare guidelines and regulations.
One year of experience with a Managed Care Health Plan.
Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards.
Ability to make determinations based on Nursing knowledge when no criteria are available or applicable.
Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance.
Clinical knowledge and critical thinking skills with the ability to assess individualized whole-person care needs necessary to develop an effective care plan.
Experience working with designated member population (e.g. behavioral health, seniors and persons with disabilities, children).

Please review the full job description on our Career’s page: https://phf.tbe.taleo.net/phf04/ats/careers/v2/viewRequisition?org=SANTCLAR2&cws=38&rid=3170

Job Type: Temporary

Pay: $100,968.00 - $151,451.00 per year

Benefits:

401(k)
401(k) matching
Dental insurance
Employee assistance program
Flexible spending account
Health insurance
Life insurance
On-site gym
Paid time off
Referral program
Retirement plan
Tuition reimbursement
Vision insurance
Wellness program

Application Question(s):

Do you have Knowledge of Milliman/MCG guidelines or other nationally accredited utilization review criteria or standards?
Do you have experience in reviewing clinical criteria to make determinations?

Experience:

licensed related health care: 1 year (Required)
Managed Care Health Plan: 1 year (Preferred)
MediCal and/or Medicare : 1 year (Required)

License/Certification:

RN License (Required)

Work Location: Hybrid remote in San Jose, CA 95119

Quick Apply

Refine Your Search

remote healthcare claims jobs in california

Utilization Management and Discharge Planning RN

VP, Healthcare Revenue Cycle, Enterprise Apps, & Data

Contract Administrator

Claim Specialist - Property Field Inspection

Supervisor, Epic Enrollment and Benefits (Tapestry) Applications (Remote Considered) )- 26-68

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Claims Examiner (Remote/Hybrid work available)

Claims Resolution Specialist

Billing Support Specialist II (Remote)

Sr. Denial Specialist (Remote)

Supervisor, Epic Enrollment and Benefits (Tapestry) Applications (Remote Considered) )- 26-68

Supervisor, Epic Enrollment and Benefits (Tapestry) Applications (Remote Considered) )- 26-68

Claims Auditor, Managed Care (remote)

Healthcare Data Analytics Consultant - CTH - Remote

Healthcare Economics Consultant - Remote

Patient Services Representative I - Remote - Nationwide

Facility Outpatient Surgical and Claims Edit Auditor (Remote)

Client Services Operations Analyst (Multi-Specialties) - Remote - Nationwide

Healthcare Revenue Cycle Billing Specialist II (SNF)

Sr. Clinical Denials Prevention Analyst (Remote)

I want to receive the latest job alert for remote healthcare claims in california

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