Medical Records Nurse

2 months ago

Long Beach CA, United States Blue Shield of California Full time

The Facility Compliance Review 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, Senior will 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. 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. 
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 FEP 
Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination and communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements 
Develop 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 appropriate 
Review itemizations for coding logic using industry standards as well as CMS guidelines
Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
Requires Bachelors of Science in Nursing or advanced degree preferred
May have practical knowledge of project management
Active AAPC or ADHIMA coding certification, eg CPC-CIC or COC with procedure coding experience (HCPCS/CPT) preferred 
Strong attention to detail to include ability to analyze claim data analytics preferred
Independent motivation, strong work ethic and strong computer navigations skills preferred

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