Utilization Management Nurse, Senior
2 weeks ago
Your Role
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.
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 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
- Clearly communicates, is collaborative, while working effectively and efficiently
- Review itemizations for coding logic using industry standards as well as CMS guidelines
- Triages and prioritizes cases to meet required turn-around times
- Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
- Clinical judgment and detailed knowledge of benefit plans used to complete review decisions
Your Knowledge and Experience
- Requires Bachelors of Science in Nursing or advanced degree preferred
- Requires a current California RN License
- Typically, requires a college degree or equivalent experience and minimum 5 years of prior relevant experience
- Typically, requires advanced knowledge of job area typically obtained through advanced education combined with experience. May have practical knowledge of project management
- Requires strong written and oral communication skills
- Requires strong analytical and problem solving skills
- 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
- Arbitration experience preferred
- DRG validation review experience preferred
Pay Range:
The pay range for this role is: $ 87230.00 to $ 130900.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
#LI-MM4
-
Utilization Management Nurse, Senior
2 weeks ago
Long Beach, United States Blue Shield of California Full timeYour Role 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...
-
Utilization Management Nurse, Senior
2 days ago
Long Beach, United States Blue Shield of California Full timeYour Role 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...
-
Utilization Management Nurse, Senior
2 weeks ago
Long Beach, United States Blue Shield of CA Full timeYour Role 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...
-
Utilization Management Nurse, Senior
1 week ago
Long Beach, United States Blue Shield of California Full timeYour Role 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...
-
Utilization Management Nurse, Senior
7 days ago
Long Beach, United States Blue Shield of California Full timeYour RoleThe 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...
-
Utilization Management Nurse, Senior
2 weeks ago
Long Beach, United States Blue Shield of California Full timeYour Role 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...
-
Utilization Management Nurse, Senior
3 days ago
Long Beach, United States Blue Shield of California Full timeJob DescriptionYour RoleThe 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...
-
Utilization Management Nurse, Senior
2 weeks ago
Long Beach, CA, United States Blue Shield of California Full timeYour Role 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...
-
Utilization Management Nurse, Senior
1 day ago
Long Beach, California, United States Blue Shield of California Full timeAbout the RoleThe Facility Compliance Review team at Blue Shield of California reviews post-service prepayment facility claims for contract compliance, industry billing standards, medical necessity, and hospital-acquired conditions/never events. As a Utilization Management Nurse, Senior, you will report to the Senior Manager, Facility Compliance Review. In...
-
Utilization Management Nurse, Senior
2 weeks ago
Long Beach, United States Blue Shield of CA Full timeYour Role The Utilization Management team reviews the inpatient stays for our members under the guidelines for nationally recognized levels of care. The Utilization Management Nurse, Senior will report to the Utilization Management Nurse Manager. In this role you will be assigned a list of inpatient facilities and review clinical information provided by the...
-
Utilization Management Nurse, Senior
5 days ago
Long Beach, CA, United States Blue Shield of California Full timeYour Role 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...
-
Utilization Management Nurse, Senior
3 weeks ago
Long Beach, CA, United States Blue Shield of California Full timeYour Role 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...
-
Senior Living Marketing Manager
5 days ago
Long Beach, California, United States Glen Park Senior Living Full timeJob OverviewAbout Glen Park Senior Living: We are committed to delivering outstanding senior living solutions that enhance the quality of life for our residents. Our focus is on creating a warm and supportive atmosphere, offering tailored services to cater to individual needs.Position Summary: We are seeking a Marketing Director/Retirement Counselor to play...
-
Utilization Management Nurse, Senior
2 weeks ago
United States, CA, Long Beach, 90802 Blue Shield of California Full timeYour Role 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...
-
Healthcare Utilization Management Associate
1 week ago
Long Beach, California, United States Saviance Technologies Full timePosition Overview:As a vital member of the Utilization Management team at Saviance Technologies, your primary focus will be on performing inpatient medical necessity assessments and utilization reviews. Your efforts will ensure that our members receive the necessary care in a timely manner. Key Responsibilities:Your daily responsibilities will...
-
Marketing Director
12 hours ago
Long Beach, California, United States Glen Park Senior Living Full timeJob SummaryWe are seeking a highly skilled Marketing Director to join our team at Glen Park Senior Living. As a key member of our senior living community, you will play a vital role in achieving maximum occupancy levels and meeting monthly benchmarks.Key ResponsibilitiesResident Onboarding and Lead Generation: Assist with resident onboarding and generate...
-
Marketing Director
5 hours ago
Long Beach, California, United States Glen Park Senior Living Full timeJob SummaryWe are seeking a highly skilled Marketing Director to join our team at Glen Park Senior Living. As a key member of our senior living community, you will play a vital role in achieving maximum occupancy levels and meeting monthly benchmarks.Key ResponsibilitiesResident Onboarding and Lead Generation: Assist with resident onboarding and generate...
-
Senior Living Marketing Executive
5 days ago
Long Beach, California, United States Glen Park Senior Living Full timeJob OverviewAbout Glen Park Senior Living: We are committed to delivering outstanding senior living services, focusing on enhancing the quality of life for our residents. Our environment is warm and supportive, ensuring personalized care tailored to individual needs.Position Summary: We are seeking a Marketing Director/Retirement Counselor to be an integral...
-
Senior IT Operations Manager
2 months ago
Long Beach, United States Nautilus Management Services Inc Full timeJob DescriptionJob DescriptionDescription:SummaryAs the Senior IT Operations Manager, with a focus on Infrastructure and End User Support, you will be responsible for managing and maintaining the organization's IT infrastructure, including all hardware and software, networks, servers, and storage devices. The Senior IT Operations Manager will also be...
-
Case Management
2 weeks ago
Long Beach, United States Blue Shield of California Full timeYour Role 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...
