Latest Nursing and Nursing Support Jobs
$63,897.60 - $83,075.20 / year
Overview: What you can expect! Find joy in serving others with IEHP! We welcome you to join us in “healing and inspiring the human spirit” and to pivot from a “job” opportunity to an authentic experience! Reporting to the Supervisor, Integrated Transitional Care, the Claims Review Nurse, LVN is responsible for conducting timely medical reviews of IEHP facility and professional claims and appeals. The Claims Review Nurse, LVN identifies process improvements in the UM/Claims interface and makes recommendations to improve the claim authorization process and business rules between Claims and UM teams. The Claims Review Nurse, LVN exercises independent judgment in conducting claims reviews and supports key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care. Commitment to Quality: The IEHP Team is committed to incorporate IEHP’s Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation. Additional Benefits: Perks IEHP is not only committed to healing and inspiring the human spirit of our Members, but we also aim to match our team members with the same energy by providing prime benefits and more. Competitive salary State of the art fitness center on-site Medical Insurance with Dental and Vision Life, short-term, and long-term disability options Career advancement opportunities and professional development Wellness programs that promote a healthy work-life balance Flexible Spending Account – Health Care/Childcare CalPERS retirement 457(b) option with a contribution match Paid life insurance for employees Pet care insurance Key Responsibilities: Audit medical necessity claims in accordance with departmental policies and procedures Act as the key clinical interface between the Claims and Medical Services departments Attend UM and Claims team meetings Review inpatient and outpatient claims that require authorization, appeals and other disputed claims in a timely manner to meet regulatory requirements Obtain the appropriate clinical information necessary to make authorization decisions for unauthorized claims Identify potential denied services/admissions/days and present to the Medical Director, both Plan and Direct, for appropriate decision/direction Review medical records to determine if charges and/or services are appropriate (e.g., reviewing CPT/HCPCS codes, up-coding practices, and similar items) Analyze level of care on in-patient reviews. Track trends in billing patterns by provider and report to leadership practices that may need further investigation Develop and sustain positive working relationships, collaborating with physicians, nurses, ancillary personnel and all others as appropriate to promote open communication channels, obtain/disseminate information, and enhance customer relations Inform appropriate staff for coordination and negotiation of financial arrangements for non-contracted and/or fee-for-service providers and facilities Provide reports as necessary Adapt to changes or unusual circumstances to promote cooperation and minimize disruption of working environment Perform any other duties as required to ensure Health Plan operations and department business needs are successful Qualifications: Education & Experience A minimum of one (1) year of relevant work experience Recent experience with inpatient and outpatient utilization and case management required Experience in auditing claims Experience in reviewing inpatient medical records and claims preferred Experience in managed care, MediCal, Medicare preferred High school diploma or GED Associate’s degree in health care or a related field from an accredited institution Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required Key Qualifications Knowledge and understanding of: CPT, ICD-10, HCPCS and hospital revenue codes Nationally recognized clinical criteria (e.g., InterQual, Milliman, Apollo) Medi-Cal, Medicare and other state/federal Program & Regulations Foundations of nursing practice and clinical pathways across inpatient, outpatient, and post‑acute settings Health plan policies, prior authorization protocols, appeals processes, and denial management Proficient in computer applications such as Word and Excel Skilled in Data Entry Skilled clinical review and judgement Data analysis and trend identification skills Communication skills (both written and verbal) Proven ability to: Exercise sound clinical judgement with minimal supervision Escalate appropriately to Medical Director for complex determinations Build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel Navigates diverse perspectives Adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality Handle PHI with strict adherence to privacy and security standards; maintains ethical audit practices Possess a strong attention to detail with the ability to multi-task Start your journey towards a thriving future with IEHP and apply TODAY ! Work Model Location: Telecommute (All IEHP positions approved for telecommute work locations may periodically be required to report to IEHP’s main campus for mandatory in-person meetings or for other business needs as determined by IEHP leadership) Pay Range: USD $63,897.60 - USD $83,075.20 /Yr. 
$130,000 - $140,000 / year
Job Description: The Pod Provider delivers comprehensive chronic disease management (e.g. hypertension, diabetes, chronic kidney disease), evaluation of acute concerns, behavioral health condition management (i.e. depression, anxiety, alcohol and substance use disorder), and preventative care and wellness support (including sexual and reproductive health). The role works collaboratively with an interdisciplinary team of clinical and non-clinical members to develop member care plans and to support members throughout their care journey. The Pod Provider also assists with the development and enhancement of clinical programs, initiatives, processes, and policies. Responsibilities: Conduct comprehensive clinical intake visits. Provide longitudinal direct primary care or wrap-around care with focus on chronic condition management and preventative care. timely follow-up for members post transition of care event, acute need or according to condition-specific needs. Proactively outreach to members who need follow up care. Complete comprehensive and compliant diagnosis capture related to HCC (Hierarchical Condition Categories) and ICD-10 (International Classification of Diseases-10) Coding. Address contractual and company-prioritized quality gaps and ensure proper chart documentation and codes (ICD or CPT) are included in the encounter as supporting evidence of gap closure. Prescribe 1st and 2nd line medications for depression, anxiety, alcohol use disorders and opioid use disorders. Remain up to date on evidence-based care for complex patients in primary care: (adult only, pediatric in certain markets). Refer member to specialist care appropriately and according to internal CBH guidance if available. Support the member in achieving the goals in their care plans (physical, behavioral, and/or social health). Participate in case conferences with the care team, providing clinical expertise on care plan development. Provide guidance on highest impact clinical interventions and tasks to achieve a member’s goals. Collaborate on a panel of members to provide clinical input, including health maintenance, chronic disease management and co-occurring psychiatric disorder support. Work Experience: 3+ experience We take into account an individual’s qualifications, skillset, and experience in determining final salary. This role is eligible for health insurance, life insurance, retirement benefits, participation in the company’s equity program, paid time off, including vacation and sick leave. The actual offer will be at the company’s sole discretion and determined by relevant business considerations, including the final candidate’s qualifications, years of experience, skillset, and geographic location. The expected salary range for this position is: 130,000 - 140,000 Cityblock values diversity as a core tenet of the work we do and the populations we serve. We are an equal opportunity employer, indiscriminate of race, religion, ethnicity, national origin, citizenship, gender, gender identity, sexual orientation, age, veteran status, disability, genetic information, or any other protected characteristic. Medical Clearance (for Member-Facing Roles): You must complete Cityblock’s medical clearance requirements, which include, but may not be limited to, evidence of immunity to MMR, Hepatitis B, Varicella, and a TB screen, or have an approved medical or religious accommodation that precludes you from being vaccinated against these diseases. We do not accept unsolicited resumes from outside recruiters/placement agencies. Cityblock will not pay fees associated with resumes presented through unsolicited means. 
Browse All Jobs → 
