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Full Time
6/1/2025
Hesperia, CA 92345
(42.0 miles)
Physical Therapist - Home Health Join our team as a dedicated Physical Therapist in Home Health, where you will help patients improve movement, manage pain, and regain independence in the comfort of their own homes. Key Responsibilities: Review patient medical histories and conduct assessments to diagnose movement dysfunction and identify patient goals.Develop and implement individualized treatment plans that may include hands-on therapy, exercises, and use of assistive equipment.Provide skilled physical therapy services in accordance with a physician’s plan of care, adapting interventions to the home environment.Educate patients and family members about the recovery process, safe mobility, and home exercise programs.Monitor and document patient progress, modifying treatment plans as needed to achieve optimal outcomes.Communicate and collaborate with physicians, nurses, and other healthcare professionals to coordinate care.Supervise and instruct Physical Therapist Assistants or Aides as required.Ensure all documentation is completed promptly and accurately in compliance with agency and regulatory standards. Work Environment: The role is based in patients’ homes, requiring travel within the community and adaptability to various home settings.This position requires strong communication, organizational skills, and the ability to work independently. Benefits: A competitive salary with opportunities for career advancement within home health or rehabilitation specialties.A comprehensive benefits package including health insurance, retirement savings plans, and paid time off.Support for continuing education programs to maintain licensure and enhance expertise in home health physical therapy. Equal Opportunity Employer: Your commitment to helping patients regain independence at home is valued here. We strive to create an inclusive environment where all employees can thrive professionally while making a meaningful difference in patients’ lives. *This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*
Full Time
6/19/2025
Long Beach, CA 90802
(36.1 miles)
Your Role The Behavioral Health Utilization Management team performs prospective utilization review for our members and correctly applies the guidelines for nationally recognized levels of care. They collaborate directly with the Member, Member's Family, and Interdisciplinary Care Team to achieve consensus and promote positive Member health outcomes through the assessment, planning, implementation, and evaluation of the Member’s Care Plan. The Licensed Clinician, Senior will report to the Manager, Behavioral Health Utilization Management. In this role you will be working with both the Utilization and Care Management teams, who provide utilization management, telephonic triage and care management assistance to members requesting access to Applied Behavioral Analysis (ABA) benefit. This role has a primary function of utilization management for our members seeking Behavioral Health Treatment (BHT).Your WorkIn this role, you will:Perform prospective utilization reviews and first level determination for members using BSC evidenced based guidelines, policies and/or nationally recognized clinal criteriaReview Functional Behavioral Assessments (FBA) and Board Certified Behavior Analyst (BCBA) Assessments submitted by providers for adherence to BACB “best practice” guidelinesGather clinical information and apply the appropriate clinical criteria/guideline, policy, and clinical judgment to render coverage determination/recommendation; prepare and present cases to Medical Director (MD) for medical director oversight and necessitydeterminationDevelop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards and identify potential quality of care issues, service or treatment delays and intervenes or as clinically appropriateAct as a liaison with caregivers, providers, and the health care community to provide information to regarding community treatment resources, mental health managed care programs, company policies and procedures, and medical necessity criteriaSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsRecognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamYour Knowledge and Experience Master’s degree in psychology or a related fieldPossesses an active BCBA certificationAt least 5 years of experience as a BCBAExpert knowledge of Applied Behavior Analysis and Autism Spectrum DisordersConsiderable knowledge of Medi-Cal Managed CareDemonstrated ability to deliver training to varied audiences and conduct effective meetingsExperience in a managed health care environment with regards to BHT servicesAbility to identify problems and works towards problem resolution independently, seeking guidance as neededAbility to represent the health plan in a professional and knowledgeable fashionAbility to express ideas clearly in both written and oral communicationsAbility to develop, organize, analyze, and implement processes and proceduresProficiency with Microsoft applications including Word, Excel, Outlook, and TeamsEffective interpersonal skills
Full Time
6/10/2025
Los Angeles, CA 90079
(42.0 miles)
Job DescriptionNomad Health seeks an experienced Emergency Room registered nurse for a travel assignment in CA.Take the next step in your healthcare career and join Nomad Health as a Emergency Room travel nurse. As a traveler with Nomad, you get access to industry-leading pay, outstanding benefits, and our knowledgeable Nomad Navigator support team.QUALIFICATIONSMinimum one year of RN experienceOne yearEmergency Room experience within the last two years as an RNHave an active RN license or be willing to obtain a Registered Nurse license in CARN degree from an accredited registered nurse programBLS and all relevant Emergency Room/department-specific certifications requiredRegister for a Nomad Health account to view full job details and applyNOMAD BENEFITSMajor medical and dental plans available on your first day of work401(k) with employer matching availableReimbursement for travel to your assignmentHousing stipendWeekly deposits direct to your bank accountWe work with thousands of travel nurses all over the country, in a wide variety of specialties and disciplines. To apply as a travel RN with us, you must have an active Professional Registered Nursing License or be willing to obtain one in the state you’re applying to, evidence of a minimum of one year RN work experience, and evidence of at least one year of Emergency Room experience within the last two years. In addition, you must have a Bachelor’s or Associate degree in nursing from an accredited registered nursing program, as well as a Basic Life Support (BLS) and all other relevant specialty/department certifications.At Nomad, we want to give you the tools you need to succeed. Our Nomad Navigators are passionate about helping you get to the bedside as quickly and efficiently as possible. They can help you with your application, credentialing, and finding housing. Our Navigators have experience working with travel nurses and can even help with on-the-job concerns if any arise while on assignment, and can provide clinician-to-clinician support.In addition to real hands-on support, we have a benefits package that was explicitly built for traveling clinicians and includes a housing stipend, partial travel reimbursement, and major medical and dental plans available on your first day of work. We also have a 401(k) program with employer matching options, a user-friendly digital timekeeping process, and weekly direct deposits.With your Nomad Health account, you get access to our unique digital platform; a platform built to help you land your perfect assignment. Move your travel healthcare career forward and find your next job today.We are seeking experienced RNs in a number of specialties to fill critical roles across the country: Medical Surgical NurseEmergency Room NurseStep-Down NurseTelemetry NurseICU NurseOperating Room NurseLabor and Delivery NurseCath Lab NursePsychiatric NurseAnd more travel RN jobs!
Full Time
6/13/2025
Pasadena, CA 91105
(40.5 miles)
When you join the Huntington Hospital team, you are aligning yourself with an organization whose values drive our philosophy of compassionate community care. Over the past 129 years, we’ve grown from a small 16-bed hospital to a nationally recognized healthcare leader with 619 beds. As part of our commitment to providing equitable, high-quality care to all members of our community, we embrace differences and work hard to create a place of belonging for our patients and our employees. When you join the Huntington family, you’ll be empowered to enact change that continuously improves our ability to deliver world-class care, with kindness and dignity, to all who need it.** Internal Workers – Please log into your Workday account to apply **Huntington Hospital Employee LoginCompensation Range:Anticipated compensation range of $62.96 - $91.72 / Hour depending on qualifications and experience.*12 hour shifts at Huntington Health are overtime-based (not a straight time rate for all 12 hours). Therefore, employees who work a full 12-hour shift will be paid their base rate for 8 hours AND overtime (1.5) for hours up to 12.Department:875100 Case ManagementExpectations:This position is responsible for facilitating care delivery and timely discharge or transfer of patients. The Case Manager manages patient flow, working to ensure that care is appropriate, authorized and conducted in the most appropriate setting. This position is vital to provide clinical information and insight to healthcare team members as well as to payer personnel. Acts as an internal resource to Revenue Cycle on clinical issues, serves as a liaison to external case managers, review organizations and insurance companies. This position requires flexibility of hours.EDUCATION:Bachelor of Science of Nursing (B.S.N.) from accredited college or university. (Degree in progress may be considered)EXPERIENCE/TRAINING:Minimum of three years of professional nursing experience in Trauma/General Surgery, Critical and/or Acute Care, Emergency Care, or equivalent education and experience. Recent experience in case management and strong discharge planning skills desirable.LICENSES/CERTIFICATIONS:Required:Current unrestricted Registered Nurse (RN) license issued by California Board of Registered Nursing (BRN)SKILLS:Exemplary communication and problem solving skills.Type minimum of 40wpm preferred. Strong computer skills.Ability to manage activities and multiple priorities within complex systems.Tolerance for ambiguity, uncertainty and change.Ability to function in unstructured environments.Worker Type:RegularFull timeShift:Evenings
Full Time
6/1/2025
Hesperia, CA 92345
(42.0 miles)
Physical Therapist - Home Health Join our team as a dedicated Physical Therapist in Home Health, where you will help patients improve movement, manage pain, and regain independence in the comfort of their own homes. Key Responsibilities: Review patient medical histories and conduct assessments to diagnose movement dysfunction and identify patient goals.Develop and implement individualized treatment plans that may include hands-on therapy, exercises, and use of assistive equipment.Provide skilled physical therapy services in accordance with a physician’s plan of care, adapting interventions to the home environment.Educate patients and family members about the recovery process, safe mobility, and home exercise programs.Monitor and document patient progress, modifying treatment plans as needed to achieve optimal outcomes.Communicate and collaborate with physicians, nurses, and other healthcare professionals to coordinate care.Supervise and instruct Physical Therapist Assistants or Aides as required.Ensure all documentation is completed promptly and accurately in compliance with agency and regulatory standards. Work Environment: The role is based in patients’ homes, requiring travel within the community and adaptability to various home settings.This position requires strong communication, organizational skills, and the ability to work independently. Benefits: A competitive salary with opportunities for career advancement within home health or rehabilitation specialties.A comprehensive benefits package including health insurance, retirement savings plans, and paid time off.Support for continuing education programs to maintain licensure and enhance expertise in home health physical therapy. Equal Opportunity Employer: Your commitment to helping patients regain independence at home is valued here. We strive to create an inclusive environment where all employees can thrive professionally while making a meaningful difference in patients’ lives. *This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*
Full Time
6/15/2025
Long Beach, CA 90802
(36.1 miles)
Your Role Reporting to the Manager, Care Management- Behavioral Health, the Licensed Clinician, Senior (ABA Case Manager) helps members with behavioral health needs navigate the health care system for linkages to behavioral health providers, treatment, and programs. This role is ideal for professionals with a background and experience in Applied Behavioral Analysis and passion for ensuring access to high quality behavioral health services. The ABA Case Manager will coordinate care and services for families, supporting members and families through their care. The ABA Case Manager will offer support in assessing members’ emotional and psychological well-being and providing resource coordination, crisis intervention, and with any general behavioral or mental health referrals. The position requires an intensive focus on crisis intervention and counseling, problem-solving and conflict resolution, patient and family management, interdisciplinary collaboration, psychosocial assessments, education, advocacy, and community resource linkages.Your WorkIn this role, you will:Collaborate with other Case Managers and Utilization Management tocomplete member assessments related to social and resource needs tosupportmemberaccess to servicesCollaborate with service coordination staff and act as liaison to ensure a timely and accurate response to member needsCollaborate with providers to support members’ treatment plan and care needsRecognize the client’s right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamAssessmembers health behaviors, cultural influences and clients belief/value systemand evaluates all information related to current/proposed treatment plan and in accordance with clinical practice guidelines to identify potential barriersEfficiently manages and maintains a caseload of members for behavioral health care coordination and or BH case management for persons experiencing severe and persistent mental illness as well as members seeking and utilizing ABA services.Maintains an active workload in accordance with National Care Manager performance standards.Provides information to members and providers regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, and company policies and procedures, and criteria.Interacts with Utilization department and Physician Advisors to discuss clinical questions and concerns regarding specific cases.Coordinates services with state and community programs on behalf of the member, particularly when the member is unable to effectively do so independentlyAs a mandated reporter, files and follows-up on reports made to the appropriate government agency (e.g., Adult Protective Services, Child Protective Services, etc.)Actively participates in Interdisciplinary Team Meetings and case consultations with Licensed Manager.)Your Knowledge and ExperienceCurrent unrestricted CA License (LCSW, LMFT, LPCC, Registered Nurse (RN), or PsyD by the Board of Behavioral Health Sciences requiredRequires at least 5 years of prior relevant experience including 3 years of experience in behavioral health or ABA, case management.Advanced degree commensurate with field is preferredBCBA PreferredExperience conducting thorough psychosocial assessments, developing care plans and providing necessary interventions identified during assessment with complex client populations that may have, among other things, inadequate coping skills, severe emotional disorders, developmental disabilities, mental illnesses, and/or unstable housingConsiderable knowledge of a wide range of psychosocial challenges and familiarity with behavioral health diagnoses and treatmentPrevious health plan or insurance experience preferred.Proficient with computer programs such as Microsoft Excel, Outlook, Word, and PowerPoint
Full Time
6/20/2025
Pasadena, CA 91105
(40.5 miles)
When you join the Huntington Hospital team, you are aligning yourself with an organization whose values drive our philosophy of compassionate community care. Over the past 129 years, we’ve grown from a small 16-bed hospital to a nationally recognized healthcare leader with 619 beds. As part of our commitment to providing equitable, high-quality care to all members of our community, we embrace differences and work hard to create a place of belonging for our patients and our employees. When you join the Huntington family, you’ll be empowered to enact change that continuously improves our ability to deliver world-class care, with kindness and dignity, to all who need it.** Internal Workers – Please log into your Workday account to apply **Huntington Hospital Employee LoginCompensation Range:Anticipated compensation range of $52.67 - $78.35 / Hour depending on qualifications and experience.*12 hour shifts at Huntington Health are overtime-based (not a straight time rate for all 12 hours). Therefore, employees who work a full 12-hour shift will be paid their base rate for 8 hours AND overtime (1.5) for hours up to 12.Department:740000 Family Birth CenterExpectations:Responsible for the coordination and management of patient flow operatives to meet department needs in antepartum, intrapartum, and postpartum to ensure an efficient operation of the departments (Labor & Delivery, Perinatal High Risk Unit, and OB-ED) by directing functions and activities; interpreting policies and procedures, standards, and regulation as applicable. Demonstrated leadership and excellent knowledge of Huntington Hospital's Customer Service Standards by being a resource role model of the department. Must possess excellent problem solving skills and knowledge of applicable laws, regulation and standards by JCAHO and other regulatory agencies. Provides administrative and clinical support to Department Manager such as new hire orientation, staff development, patient care plan update, communication to staff nurses during shift changes, etc. Performs duties in any nursing capacity as needed. Meets Qualifications for Registered Nurse Job Description. This position may require flexibility of hours.EDUCATION:Bachelor’s degree (BSN) required. Associate Degree in Nursing (ADN) will be considered if enrolled in a BSN program with degree completion within 2 years of date of hire or date of transfer to an RN position. Diploma or transcripts on highest degree earned required.EXPERIENCE/TRAINING:Minimum 2 years of current experience in area of expertise/equivalent service area required.Leadership experience preferred.Basic computer skills/experience with computerized documentation systems required.LICENSES/CERTIFICATIONS:Required:Current unrestricted Registered Nurse (RN) license issued by California Board of Registered Nursing (BRN)Current Basic Life Support Provider (BLS), Advanced Cardiovascular Life Support Provider (ACLS) issued by American Heart AssociationCurrent Neonatal Resuscitation Provider (NRP) Preferred:Current Inpatient Obstetric Nursing (RNC-OB) or equivalent certificationSKILLS:Advanced Fetal Monitoring Certification required.Worker Type:RegularFull timeShift:Nights
Full Time
6/6/2025
Long Beach, CA 90802
(36.1 miles)
Your Role The Facility Compliance Review (FCR)team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events. The Utilization Management Nurse, Seniorwill report to the Senior Manager, Facility Compliance Review. In this role you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. This role will be focusing primarily on inpatient psych reviews for Residential Treatment and Detox. Also, you will be reviewing hospital itemized bills for a comprehensive line-by-line audit and manual claims processing on exceptions to ensure that appropriate billing practices are followed based on facility specific contract language. These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing.Your Work In this role, you will: Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEPConducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliancePrepare and present cases to Medical Director (MD) for medical director oversight and necessity determinationand communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirementsDevelop and review member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standardsandidentifypotential quality of care issues, service or treatment delays and intervenes or as clinically appropriateClearly communicates, is collaborative, while working effectively and efficientlyReview itemizations for coding logic using industry standards as well as CMS guidelinesTriages and prioritizes cases to meet required turn-around timesIdentifies potential quality of care issues, service or treatment delays as clinically appropriate.Clinical judgment and detailed knowledge of benefit plans used to complete review decisionsYour Knowledge and Experience Requires a bachelor's degree or equivalent experienceRequires a current California RN LicenseRequires at least 5 years of prior relevant experiencePrevious Inpatient Psych experience preferredRequires strong attention to detail to include ability to analyze claim data analyticsRequires independent motivation, strong work ethic and strong computer navigations skillsPsych claims review experience preferred
Full Time
6/6/2025
Long Beach, CA 90802
(36.1 miles)
YourRole TheCareManagement Department is seeking adedicated and compassionate Clinical Service Coordinator (CSC) to join our team.The Clinical Service Coordinatorwill report to the SupervisorofCare Operations.The CSC will play a vital role in outreach and engagement efforts with our members, introducing them to care management services, and conducting assessments to identify their needs. The successful candidate willinteract telephonically with members to assist with simple care coordination needs and facilitate connections between members and appropriate services, including internal nurse care managers, vendors, and behavioral health providers.YourWork Inthisrole,youwill:Conduct telephonic outreach efforts to engage members andintroduce them to care management services.CompletethoroughassessmentstoidentifymemberneedsandcaregapsMaintain accurateand up-to-datememberrecordsanddocumentation ofall interactions and services providedConductfollow-upcallstoensuremembers’needsarebeingmetProvide members with information and resources about available care management services and how to access themProvidesadministrative/clericalsupporttomedicalanddiseasemanagementprograms.Acts as aliaison, gathers information, and track all patients referred to the care management programs.Assists in coordinating care for specific high risk/high-cost patient population, including referrals tocommunity resources, facilitation ofmedical services, referral to ancillary providers,etc.Assistsinverifyinghealthplanbenefitsandcoordinatingambulatoryservices.Demonstratesculturalcompetencetoworkeffectively,respectfully,andsensitivelywithin the client’s cultural context.Assistswithpreceptingresponsibilitiesfornewhiresandauditingefforts. YourKnowledgeandExperience AminimumofahighschooldiplomaAminimumof3yearsofrelevantexperienceAminimumof1yearexperienceinamanagedcareenvironment.Bi-Lingual: Must be fluent in English and SpanishHealthinsurance/managedcareexperience(Commercial,Medicare,andMedi-Cal)CommunityresourcesandadvocacyAbilitytoidentifyissuesanddevelopeffectivesolutionstomeetmembers'needsFlexibilitytoadjusttochangingcircumstancesandmemberneedsStrong verbal and written communication skills to effectively convey information to members and colleagues
Full Time
6/13/2025
Glendale, CA 91206
(44.4 miles)
Radiology Technologist - Radiation Therapy Join our team as a skilled Radiology Technologist - Radiation Therapy, where you will play a vital role in delivering targeted radiation treatments to patients diagnosed with cancer or other conditions. This position is ideal for professionals passionate about using advanced technology to improve patient outcomes. Key Responsibilities: Administer radiation treatments as prescribed by oncologists, ensuring precision and patient safety.Operate radiation therapy equipment such as linear accelerators to deliver targeted doses of radiation.Monitor patients during treatments and provide immediate assistance if complications arise.Collaborate with oncologists, medical physicists, and other healthcare professionals to develop treatment plans.Maintain accurate records of treatments provided and ensure compliance with safety protocols. Work Environment: The role is based in hospitals or specialized oncology centers equipped with advanced radiation therapy technology.This position requires attention to detail in a fast-paced environment while adhering to strict safety standards for both patients and staff members. Benefits: A competitive salary with opportunities for career advancement within the field of radiation therapy.A comprehensive benefits package including health insurance, retirement savings plans, and paid time off.Support for continuing education programs to maintain certifications and expand expertise in radiation therapy techniques. Equal Opportunity Employer: Your dedication to improving patient outcomes through advanced imaging and treatment technologies is valued here. We strive to create an inclusive environment where all employees can excel professionally while contributing meaningfully to patient care excellence. *This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*
Full Time
6/19/2025
Long Beach, CA 90802
(36.1 miles)
Your Role The Behavioral Health Utilization Management team performs prospective & concurrent utilization reviews and first level determinations for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business. The Behavioral Health Utilization Management Clinician, Senior, will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role you will conduct clinical review of mental health and substance use authorization requests at various levels of care for medical necessity, coding accuracy, medical policy compliance and contract compliance.Your Work In this role, you will: Perform prospective & concurrent utilization reviews and first level determination approvals for members admitted to facilities using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare as neededGather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director oversight and necessity determinationProvide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteriaWork with multidisciplinary teams to support members using an integrated team-based approach including Interdisciplinary Team Meetings and case consultations with Medical Director and/or Licensed ManagerRecognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsYour Knowledge and Experience Current unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) requiredAdvanced degree commensurate with field is preferredRequires at least five (5) years of prior experience in healthcare related fieldThree (3) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment requiredStrong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelinesFamiliarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab resultsProficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databasesExcellent analytical, communication skills, written skills, time management, and organizational skillsPossess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiativeAbility to identify problems and works towards problem resolution independently, seeking guidance as needed
Full Time
6/6/2025
Long Beach, CA 90802
(36.1 miles)
Your Role The Behavioral Health Utilization Management team performs prospective, concurrent, retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies, and nationally recognized clinal criteria across multiple lines of business. The Licensed Clinician, Senior, will report to the Manager of Behavioral Health Utilization Management (BH UM). In this role you will conduct clinical review of mental health and substance use authorization requests at various levels of care for medical necessity, coding accuracy, medical policy compliance and contract compliance.Your Work In this role, you will: Perform prospective, concurrent and retrospective utilization reviews and first level determination approvals for members admitted to inpatient facilities using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare as neededGather clinical information and apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care facilitates including effective discharge planning at levels of care appropriate for the members needs and acuity; prepare and present cases to Medical Director (MD) for medical director oversight and necessity determinationProvide information to facilities and providers regarding community treatment resources, mental health care management programs, company policies and procedures, and medical necessity criteriaWork with multidisciplinary teams to support members using an integrated team-based approach including Interdisciplinary Team Meetings and case consultations with Medical Director and/or Licensed ManagerRecognize the members right to self-determination as it relates to the ethical principle of autonomy, including the members/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamSupport team through consistent and successful caseload management and workload to achieve team goals, regulatory timelines, and accreditation standardsYour Knowledge and Experience Bachelor of Science or advanced degree preferredCurrent unrestricted CA license (LCSW, LMFT, LPCC, Licensed Psychologist, or Registered Nurse (RN) with Behavioral Health experience)Requires at least five (5) years of prior experience in healthcare related fieldThree (3) years conducting Behavioral Health Utilization Management for a health insurance plan or managed care environment preferredStrong understanding of Behavioral Health Utilization Management including ability to apply and interpret admission and continued stay criteria of multiple standardized clinical criteria sets including but not limited to MCG guidelines, nonprofit association guidelines, and various Medicare guidelinesFamiliarity with medical terminology, diagnostic terms, and treatment modalities including ability to comprehend psychiatric evaluations, clinical notes, and lab resultsProficient with Microsoft Excel, Outlook, Word, Power Point, and the ability to learn and utilize multiple systems/databasesExcellent analytical, communication skills, written skills, time management, and organizational skillsPossess outstanding interpersonal, organizational, and communication skills, positive attitude, and high level of initiativeAbility to identify problems and works towards problem resolution independently, seeking guidance as needed
Full Time
5/29/2025
Long Beach, CA 90802
(36.1 miles)
Your Role Work schedule is Mon-Fri 10am- 7pm The Federal Employee Program (FEP) team performs integrated case management (CM) and disease management (DM) activities demonstrating clinical judgment and independent analysis, collaborating with members and those involved with members’ care including clinical nurses and treating physicians. The Regional Registered Nurse Case Manager will report to the FEP Care Management Department Manager. In this role you will determine, develop, and implement a plan of care based on accurate and comprehensive assessment of the member’s needsYour WorkIn this role, you will:Coordinate care for lower level of care such Skilled Nursing Facility, Home Health, Home Infusion, Acute Rehab, Long-term Acute Care Hospital, Hospice, and other community program as appropriatePerform effective discharge planning and collaborate with member’s support system and health care professionals involved in the continuum of careProvides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease). Outreach to members with HEDIS Care Gaps to assist with closureApply detailed knowledge of FEP PPO and Blue Shield of California's established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each caseResearch and design treatment/care plans to promote quality of care, cost effective health care services based on medical necessity complying withcontract for each appropriate plan typeProvide Referrals to QualityManagement (QM), Disease Management (DM) and Appeals and Grievance department (AGD)Recognize the clients right to self-determination as it relates to the ethical principle of autonomy, including the client/family's right to make informed choices that may not promote the best outcomes, as determined by the healthcare teamDesign appropriate and fiscally responsible plan of care with targeted interventions that enhance quality, access and cost-effective outcomesInitiate and implement appropriate modifications in plan of care to adapt to changes occurring over time and through various settingsMust be able to sit for extended periods of time and read information on one computer screen and apply that information on a second computer screen to complete documentationYour Knowledge and ExperienceRequires a current CA RN License.Bachelor of Science in Nursing or advanced degree preferredCertified Case Manager (CCM) Certification or is in process of completing certification when eligible based on CCM application requirementsRequires at least 5 years of prior experience in nursing, healthcare or related field3+ years managed care experience preferred.Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources preferredBehavioral health, oncology, or OB/NICU/pediatrics experience preferredStrong electronic clinical documentation skills, independent problem identification and resolution skillsKnowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirableCompetent understanding of NCQA and federal regulatory requirementsDemonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-makingDemonstrates professional judgment, and critical thinking, to promote the delivery of quality, cost-effective care. This judgment is based on medical necessity including intensity of service and severity of illness within contracted benefits and appropriate level of care
Full Time
6/10/2025
Long Beach, CA 90899
(34.2 miles)
Your Role The Network Contracting and Trend Analytics (NTA) team supports the Network Management team with analytical and financial modeling for provider contracting and network development activities for Blue Shield of California. The Senior Principal, Medical Informatics of NTA will report to the Senior Director of NTA. In this role you will be responsible for behavioral health finance analytics including measurement of internal cost of healthcare and reporting, analytics supporting coordination of care opportunities, and oversight of provider contracting analytics. Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.Your Work In this role, you will: Develop the financial management and modeling best practices, specifically for Behavior Health as we move to an in-sourced environmentImplement on-going behavior health costs analysis and trendsBe responsible for CoHC - Behavior HealthBe the lead on modeling the financial aspects. Example, evaluating the financial aspects of care activities such as hospital ER vs behavioral health servicesLead all financial aspects in developing Value-Based Contracting, specifically in Behavior Health marketplace.Be accountable for development of the financial contractual arrangements and the implementation of these providers, which we are bringing in house Your Knowledge and Experience Requires a college degree or equivalent experienceMPH, MBA, MS, MA, RN, or RHIA preferredRequires 10 years of relative experienceRequires a minimum of 5 years’ experience in Health Care (managed care, academic, or gov't payer)Requires contracting in healthcare with a behavioral health specialtyRequires experience developing programs that will translate into CoHC savings specifically in extensive vendor knowledge of financial healthcare within behavioral healthRequires experience with behavioral health financial reporting and modelingRequires one to be comfortable with an ever changing business model that is continually seeking the optimal solution in the behavioral health spaceRequires a SAS Certified Base Programmer Credential or equivalent or a SAS Certified Advanced Programmer Credential or equivalent
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