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Healthcare Jobs
Full Time
6/13/2025
Sacramento, CA 95820
(28.6 miles)
Physical Therapist - RehabWe are seeking a dedicated Physical Therapist to join our rehabilitation team. In this role, you will help patients recover from injuries or illnesses by improving their movement, reducing pain, and restoring functionality through personalized therapy programs.Key Responsibilities:Evaluate patients to assess their physical conditions and develop individualized treatment plans.Implement therapeutic exercises, manual therapy techniques, and specialized equipment to aid recovery.Educate patients and caregivers on techniques to improve mobility and prevent future injuries.Collaborate with other healthcare professionals to ensure comprehensive care for patients.Monitor patient progress and adjust treatment plans as necessary to achieve optimal outcomes.Document patient evaluations, treatments, and progress in compliance with healthcare regulations.Work Environment:Work in rehabilitation centers, hospitals, outpatient clinics, or private practices specializing in physical therapy.Engage in a dynamic, hands-on environment that requires physical activity and patient interaction.Benefits:Competitive salary and comprehensive benefits package.Opportunities for professional growth through training and certifications.A supportive work environment focused on collaboration and innovation in patient care delivery.*This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*
Full Time
7/6/2025
Carmichael, CA 95608
(19.7 miles)
We. Are. OneStaff. Medical. An independently-owned, nationally-recognized and amazingly awesome staffing firm ready to work for you! A work ethic forged in the Midwest, we are here to stand by your side and help you find your dream assignment anywhere in this great country. We want the same like-minded, awesome candidates to travel with us. Be bold. Enjoy work again. Let us help. THE POSITION: A physical therapist will examine a patient and focus on creating a recovery plan. They focus on treatments that reduce the need for surgery and prescriptive drugs. A physical therapist uses a combination of exercises, stretches, hands-on techniques and equipment to restore function or relieve pain. *Weekly amount stated in the job postings is scaled based on estimated hourly wages and potential stipends available for the location of the assignment. Hourly wages are based on various factors including but not limited to: experience, demand, availability, location, etc. Please contact one of our amazing OneStaff Recruiting Specialists for more details. **Equal Opportunity Employer** BENEFITS: Insurance We provide group benefits for Health, Dental, Vision, Life, Short Term Disability, Long Term Disability, Accident, Critical Illness, and Identity Theft Protection. 401K You are eligible to enroll 1st of the month following hire date. We match 100% of your first 3% of deferrals and an additional 50% of the next 2% you contribute. Employee Assistance Program Free to all employees who’d like information on personal issues: Education, Dependent Care, Care Giving, Legal, Financial, Lifestyle & Fitness Management, Working Smarter.
Full Time
6/19/2025
El Dorado Hills, CA 95762
(14.2 miles)
Your Role The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Medical Director, Behavioral Health will report to the Senior Medical Director, Behavioral Health. In this role you will have core responsibilities in the areas of behavioral health concurrent review, pre- and post-service utilization review, and collaboration with Clinical Care Managers. 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: Review concurrent, pre- and post-service behavioral health service requests and render decisions based on the member's benefits, medical necessity, Blue Shield of California medical policy, FEP (Federal Employee Program) medical policy, as well as legal and regulatory requirementsMedical decision and support for the behavioral health review for all services currently requiring authorization or review, facilitating appropriate use of all resources, including safe and timely dischargesEngage in telephonic peer-to-peer discussions regarding current members in various levels of care or who may be receiving other specialized services. Therefore, the Medical Director must feel comfortable in clinical conversations with Blue Shield providersTrain BSC utilization and care management staff which may include physicians, psychologists, nurses, social workers, and others as neededPerform clinical reviews to support utilization management and fraud waste and abuse case evaluationsParticipate with the quality management function in the identification and analysis of medical information to develop interventions to improve quality of care and outcomes for our membersParticipate on projects and committees, as necessaryYour Knowledge and ExperienceMinimum 5 years direct patient behavioral health clinical care experience post residency requiredMedical degree (M.D./D.O.)Completed residency in PsychiatryMaintain active, unrestricted California Medical License required; Maintain active, unrestricted Medical License in all additional assigned states requiredMaintain Board Certification in Psychiatry through American Board of Psychology and Neurology (ABPN) or the American Osteopathic Board of Neurology and Psychiatry (AOBNP) requiredPreferred Qualifications:Recent inpatient psychiatric hospital experience (within the past five years)Recent substance use disorders treatment experience (within the past five years)Well-versed with most areas of behavioral health services and conditionsShow ability for rapid, accurate decision-making, and enjoy care review, as well as the investigation and resolution of complex issuesExperience with CPT coding, medical claims review, hospital billing, and reimbursementDeep knowledge of MHPAEA (Mental Health Parity and Addiction Equity Act), SB855 and all regulatory and compliance requirementsManaged care experience supporting utilization management, case review, and/or quality improvement activities in behavioral healthExperience with ASAM, LOCUS, CALOCUS, and WPATH
Full Time
7/6/2025
Sacramento, CA 95816
(27.3 miles)
We. Are. OneStaff. Medical. An independently-owned, nationally-recognized and amazingly awesome staffing firm ready to work for you! A work ethic forged in the Midwest, we are here to stand by your side and help you find your dream assignment anywhere in this great country. We want the same like-minded, awesome candidates to travel with us. Be bold. Enjoy work again. Let us help. THE POSITION: Speech Therapist work with patients across multiple age groups to facilitate the treatment of speech and language disorders, such as stammers, stutters, Tourettes and mutism. *Weekly amount stated in the job postings is scaled based on estimated hourly wages and potential stipends available for the location of the assignment. Hourly wages are based on various factors including but not limited to: experience, demand, availability, location, etc. Please contact one of our amazing OneStaff Recruiting Specialists for more details. **Equal Opportunity Employer** BENEFITS: Insurance We provide group benefits for Health, Dental, Vision, Life, Short Term Disability, Long Term Disability, Accident, Critical Illness, and Identity Theft Protection. 401K You are eligible to enroll 1st of the month following hire date. We match 100% of your first 3% of deferrals and an additional 50% of the next 2% you contribute. Employee Assistance Program Free to all employees who’d like information on personal issues: Education, Dependent Care, Care Giving, Legal, Financial, Lifestyle & Fitness Management, Working Smarter.
Full Time
6/19/2025
El Dorado Hills, CA 95762
(14.2 miles)
Your Role The Behavioral Health Registered Nurse Case Manager will report to the FEP 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 needs. 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. documentation.Your Work In this role, you will: Coordinates care for Lower Level of Care such as Residential Treatment, Partial Hospitalization Program, Intensive Outpatient Program, other outpatient services, and community programs as appropriate.Research 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 settingsApplies detailed knowledge of FEP PPO and Blue Shield of California's (BSC) established medical/departmental policies, clinical practice guidelines, community resources, contracting and community care standards to each case.Performs effective discharge planning and collaborates with member support system and health care professionals involved in the continuum of care.Provides disease management education on core chronic conditions (Diabetes, Heart Failure, COPD, Asthma and Coronary Artery Disease).Determines, develops and implements a plan of care based on accurate and comprehensive assessment of the member's needs related to behavioral health.Must 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 documentation.Your Knowledge and Experience Requires a current CA RN LicenseCertified 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 fieldBachelor of Science in Nursing or advanced degree preferred.Requires relevant behavioral health experience.Comprehensive knowledge of case management, discharge planning, utilization management, disease management and community resources.Able to operate PC-based software programs including proficiency in Word and Excel.Strong clinical documentation skills, independent problem identification and resolution skills.Strong supervisory, communication, abstracting skills with strong verbal and written communication skills and negotiation skills.Competent understanding of NCQA and federal regulatory requirements.Knowledge of coordination of care, prior authorization, level of care and length of stay criteria sets desirable.Demonstrates 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.Demonstrate leadership, project management and program evaluation skills and ability to interact with all levels including senior management and influence decision-making.
Full Time
7/6/2025
Sacramento, CA 95816
(27.3 miles)
We. Are. OneStaff. Medical. An independently-owned, nationally-recognized and amazingly awesome staffing firm ready to work for you! A work ethic forged in the Midwest, we are here to stand by your side and help you find your dream assignment anywhere in this great country. We want the same like-minded, awesome candidates to travel with us. Be bold. Enjoy work again. Let us help. THE POSITION: Speech Therapist work with patients across multiple age groups to facilitate the treatment of speech and language disorders, such as stammers, stutters, Tourettes and mutism. *Weekly amount stated in the job postings is scaled based on estimated hourly wages and potential stipends available for the location of the assignment. Hourly wages are based on various factors including but not limited to: experience, demand, availability, location, etc. Please contact one of our amazing OneStaff Recruiting Specialists for more details. **Equal Opportunity Employer** BENEFITS: Insurance We provide group benefits for Health, Dental, Vision, Life, Short Term Disability, Long Term Disability, Accident, Critical Illness, and Identity Theft Protection. 401K You are eligible to enroll 1st of the month following hire date. We match 100% of your first 3% of deferrals and an additional 50% of the next 2% you contribute. Employee Assistance Program Free to all employees who’d like information on personal issues: Education, Dependent Care, Care Giving, Legal, Financial, Lifestyle & Fitness Management, Working Smarter.
Full Time
6/15/2025
El Dorado Hills, CA 95762
(14.2 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
7/6/2025
Sacramento, CA 95817
(28.1 miles)
We. Are. OneStaff. Medical. An independently-owned, nationally-recognized and amazingly awesome staffing firm ready to work for you! A work ethic forged in the Midwest, we are here to stand by your side and help you find your dream assignment anywhere in this great country. We want the same like-minded, awesome candidates to travel with us. Be bold. Enjoy work again. Let us help. THE POSITION: Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. It can be used as a way to diagnose heart conditions, or as treatment. Cardiac Cath Lab Nurses assist doctors performing these procedures. As a Cardiac Cath Lab Nurse, you can specialize even further in coronary catherizationprocedures that involve coronary arteries, and take place in state of the art labs. In this specialty, you’ll have the opportunity to work with the latest technology in cardiac care. *Weekly amount stated in the job postings is scaled based on estimated hourly wages and potential stipends available for the location of the assignment. Hourly wages are based on various factors including but not limited to: experience, demand, availability, location, etc. Please contact one of our amazing OneStaff Recruiting Specialists for more details. **Equal Opportunity Employer** BENEFITS: Insurance We provide group benefits for Health, Dental, Vision, Life, Short Term Disability, Long Term Disability, Accident, Critical Illness, and Identity Theft Protection. 401K You are eligible to enroll 1st of the month following hire date. We match 100% of your first 3% of deferrals and an additional 50% of the next 2% you contribute. Employee Assistance Program Free to all employees who’d like information on personal issues: Education, Dependent Care, Care Giving, Legal, Financial, Lifestyle & Fitness Management, Working Smarter.
Full Time
6/10/2025
El Dorado Hills, CA 95762
(14.2 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
6/20/2025
Folsom, CA 95630
(14.3 miles)
Registered Nurse (RN) - Labor and Delivery Join our team as a compassionate Registered Nurse (RN) in Labor and Delivery, where you will provide specialized care to expectant mothers during childbirth and postpartum recovery. This role involves supporting families during critical moments of their lives. Key Responsibilities: Assess and monitor the health status of pregnant women during labor, ensuring timely interventions when necessary.Administer medications and treatments as prescribed by physicians, monitoring patients for any adverse reactions.Support patients during delivery, providing emotional support and guidance throughout the process.Collaborate with healthcare teams to develop individualized care plans for mothers and newborns.Educate patients and families on postpartum care, breastfeeding techniques, and newborn care strategies.Document patient information accurately in medical records, ensuring compliance with regulatory standards. Work Environment: The role is based in hospital labor and delivery units where RNs work closely with expectant mothers and newborns.This position requires strong communication skills and the ability to work effectively in a dynamic, fast-paced environment. Benefits: A competitive salary with opportunities for career advancement within obstetric nursing 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 labor and delivery nursing practices. Equal Opportunity Employer: Your dedication to supporting maternal health is valued here. We strive to create an inclusive environment where all employees can thrive professionally while delivering exceptional care during critical moments of childbirth. *This information is based on general job descriptions. Actual job responsibilities may vary by location.*
Full Time
6/10/2025
El Dorado Hills, CA 95762
(14.2 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, Experienced, 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 WorkIn 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 ExperienceCurrent unrestricted CA license (LCSW, LMFT, LPCC, PhD/PsyD or RN with Behavioral Health experience) requiredAdvanced degree commensurate with field is preferredRequires at least three (3) years of prior experience in healthcare related fieldOne (1) year 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
6/19/2025
Sacramento, CA 95817
(28.1 miles)
Registered Nurse (RN) - Operating Room (OR) We are seeking a skilled Registered Nurse (RN) for our Operating Room (OR), where you will assist surgical teams in providing safe and effective patient care during various surgical procedures. Key Responsibilities: Prepare operating rooms by sterilizing instruments, setting up equipment, and ensuring all necessary supplies are available.Assist surgeons during procedures by maintaining sterile fields and handing instruments efficiently.Monitor patient vital signs throughout surgery and respond promptly to any changes or complications.Coordinate with surgical teams to develop individualized patient care plans before, during, and after surgery.Provide patient education regarding surgical procedures, recovery expectations, and postoperative care instructions.Accurately document surgical procedures and patient responses in medical records. Work Environment: This position is based in hospital operating rooms or outpatient surgical centers equipped with advanced surgical technology.The role requires precision, teamwork, and the ability to perform effectively in high-stress environments. Benefits: A competitive salary with opportunities for advancement within perioperative nursing specialties.A comprehensive benefits package including health insurance, retirement plans, and paid time off.Support for continuing education programs to maintain licensure and enhance operating room nursing skills. Equal Opportunity Employer: Your dedication to surgical excellence is valued here. We strive for an inclusive environment where all employees can excel professionally while contributing significantly to patient outcomes during surgery. *This information is based on the Bureau of Labor Statistics (BLS). Actual job responsibilities may vary by location.*
Full Time
6/10/2025
El Dorado Hills, CA 95762
(14.2 miles)
Your Role The Medical Management team ensures that Blue Shield is on the cutting edge of medical, medication, and payment policy to accelerate the emergence of a value-based health care system in California. The Sr. Medical Director, Medical Policy will report to the Chief Medical Officer. In this role you will be accountable for ensuring that all medical, medication, and payment policy initiatives are in aligned with the scientific evidence and professional guidelines. You will lead a team that delivers medical policy that adapts to new clinical innovations and supports medical payment operations, and training for staff in the accurate application of medical, medication, and payment policy, pricing, and coding. In addition to chairing the BSC Pharmacy & Therapeutics, Medical and Payment Policy Committees, you will provide clinical leadership for all evidence-based medicine functions and partner closely with leaders of other business functions to develop strategies to ensure that Blue Shield members are receiving appropriate quality care.Your WorkIn this role, you will:Provide clinical thought leadership for the design and implementation of clinical policy innovation initiatives such as Coverage with Evidence Development, and the development of robust and efficient approaches to developing policies for emerging classes of technology like molecular diagnostics and mobile/digital personal health devicesChair the Medical Policy and Pharmacy and Therapeutics CommitteesProvide clinical leadership and medical consultation for the Blue Shield of California (BSC) medication management process, including working closely with the Pharmacy Services team to promote safe, effective, and cost-efficientProvide medical expertise in daily clinical rounds for drug authorization case reviewChair the Payment Policy Committee and provide clinical leadership for the BSC Payment Policy committee, overseeing and advising about payment policies and tactical approaches to ensure accurate coding of servicesConsult with BSC legal team to support fraud and abuse investigations, provider arbitrations, regulatory inquiries and issues, and litigation related to clinical policy, coding, or pricing issuesAct as BSC’s representative to the Blue Cross Blue Shield Association (BCBSA) Technology Assessment process and the Medical Policy PanelParticipate on the California Technology Assessment Forum and other related activitiesPartner with Network Management and Provider Partnership teams by providing subject matter expertise for contract and benefits coding decisions, including mandated benefits, provider contract language, provider DOFRs (division of financial responsibilities), and providing clinical perspective to resolve issues with BSC providers related to clinical policy, coding, and billing.Provide subject matter expertise for pricing of new, zero-dollar, and other exceptional claimsPresent at IPA/MG and Provider education seminars regarding medical, medication and payment policy Your Knowledge and ExperienceMinimum of 2 years of previous medical leadership experienceMinimum of 5 years of direct patient care experience post residencyMinimum of 8 years of experience developing evidence-based guidelines, medical policies or performing systematic reviews of the medical literatureMedical degree (M.D./D.O.) required. Master’s degree in epidemiology, health services or related degree is preferredCompleted residency preferably in adult based primary care specialty (e.g. Internal Medicine, Family Practice)Maintain active, unrestricted California State Medical License required; Maintain active, unrestricted Medical License in all additional assigned states requiredMaintain Board Certification in one of ABMS, ABOS, or AOA recognized specialty required (preferably Internal Medicine or Family Practice)Has mastery level knowledge and skills within a specific technical or professional discipline with broad understanding of other areas within the job functionOutstanding verbal and written communication skillsAbility to lead through influence in a matrixed organizationExperience performing utilization management reviews is preferredExperience in a health plan or managed care organization is preferred#LI-JS3
Full Time
6/10/2025
El Dorado Hills, CA 95762
(14.2 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 Manager, Utilization Management Nurse Management will report to the Senior Manager, Facility Compliance Review . In this role you will be responsible for several direct reports, be a resource for problem solving issues, training and updating documentation as needed. You will work to enhance the department’s operations with efficiency and attention to detail/quality.Your Work In this role, you will: Establish operational objectives for department or functional area and participate with other managers to establish group objectivesBe responsible for team, department or functional area results in terms of planning, cost in collaboration with Sr ManagerDevelop and maintain FCR workflows, protocols, and policies to ensure efficient and effective care coordinationEnsure workflow procedures and guidelines are clearly documented and communicatedInterpret or initiate changes in guidelines/policies/proceduresMonitor and evaluate the performance of the FCR team and implement improvement strategies as neededKeeps team focused on specific and measurable performance goals and monitors performance against clear standards.Works collaboratively among business units to align and partner with others to achieve performance goals and/or outcomesProvide Ensure the delivery of high-quality, patient-centered care through the management of chronic disease, complex case management, and discharge planningOther duties as assigned by Sr ManagerYour Knowledge and Experience Requires a current CA RN LicenseBachelors of Science in Nursing or advanced degree preferred.Requires at least 7 years of prior relevant experience including 3 years of management experience gained as a team leader, supervisor, or project/program managerA minimum of 3+ year experience in inpatient or managed care environment preferredExcellent communication, interpersonal, and negotiation skillsHas functional expertise within the area of responsibility.Knowledge of NCQA requirements preferredAbility to analyze data and create reports to guide decision-making and process improvements
Full Time
6/10/2025
El Dorado Hills, CA 95762
(14.2 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
6/10/2025
El Dorado Hills, CA 95762
(14.2 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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