Clinical Review Nurse

South San Francisco, CA 94080

Posted: 04/03/2019 Employment Type: Direct Hire Industry: Clinical & Scientific Job Number: 15431

Bayside  Solutions is seeking a Clinical Review Nurse  to be a part of our partner’ s team in the South San Francisco. This is an opportunity to provide access to a stable and comprehensive network of providers, and a benefits program that promotes preventive care with staff devoted to ensuring Medi-Cal patients receive high quality, coordinated health care.

Our Company Bio:  Bayside Solutions was founded in 2001, Bayside was recognized as one of the fastest growing professional staffing companies in Northern California. The numbers tell the story: We have close to a 100% client retention rate, 700% growth in four plus years and over 95% repeat business. Our dedication to building partnership relationships with both our clients and our recruits is the key to our phenomenal success.

You can find additional information on our company website at

Clinical Review Nurse

Job Benefits:
  • An opportunity to join a local non-profit health care plan that offers health coverage and a provider network to San Mateo County' s under-insured population.
  • Company that currently serve more than 145, 000 County Residents
  • Competitive compensation commensurate with experience
  • Excellent benefits package offered, including paid premiums for employee’ s coverage in the medical HMO plan and majority of PPO medical cost.

Summary of Responsibilities:
  • Perform preliminary clinical reviews of all new grievances and appeals to determine whether complaints meet the clinical criteria to be expedited, whether additional medical records are needed, and whether the complaint involves a potential quality of care concern.
  • Conduct and document clinical reviews, including SBARs (situation, background, assessment, and recommendation), for all appeals of medical treatments, procedures, and items.
  • Appropriately utilize relevant clinical guidelines to determine medical necessity and benefit coverage criteria for appeals, including but not limited to Milliman Care Guidelines, Noridian Guidelines, the Medi-Cal Provider Manual, and the applicable Evidence of Coverage/Member Handbook.
  • Make recommendations to the Medical Director regarding coverage of medical services.
  • Using case notes, medical records, written responses from providers, and all other relevant documentation, clinically evaluate reports of Potential Quality Incidents (PQI) and Quality of Care (QOC) complaints.
  • Assign PQI and QOC reports a rating of severity, based on established guidelines, and help to identify interventions as needed.
  • Review reports to identify trends in grievances and appeals; make recommendations based on trends identified.
  • Collaborate with internal and external stakeholders to identify and act on opportunities for improvement in the area(s) of utilization management and quality of care.
  • Act as a clinical resource for the G&A Unit in reviewing and resolving complaints.
  • Assist with care coordination for members involved in the grievance or appeals process.
  • Perform other duties as assigned.

Required Qualifications:

Education and Experience:
  • Bachelor’ s degree in nursing or a related health services field is a plus.
  • Two (2+) plus years of relevant nursing experience in a managed care, utilization management, disease management, quality improvement, or case management setting.

Knowledge of: Principles and methods of utilization management, including standardized clinical guidelines. Best practices for quality of care. Medi-Cal and Medicare coverage requirements and regulatory guidelines (strongly preferred). Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint. Ability to work in collaboration with a service team where the expectation is to contribute to cases using a dispatcher/case management system.

Ability to: Evaluate medical records and other health care data. Ensure medical appropriateness and effective utilization of health care resources. Work with both clinical and non-clinical staff to resolve member issues. Respond quickly to requests and conduct clinical reviews in an efficient manner. Establish and maintain effective and cooperative working relationships with all levels of staff as well as plan partners from other programs, agencies, and the general public. Maintain accurate records and confidentiality of sensitive medical information. Assume responsibility and exercise good judgment in making decisions within the scope of authority of the position. Accurately complete tasks within established times and to effectively prioritize multiple tasks and deadlines. Communicate effectively, both verbally and in writing, with individuals from varying cultural and ethnic backgrounds.
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