Senior Utilization Management Nurse
4 weeks ago
We are seeking a highly skilled Senior Utilization Management Nurse to join our team at Blue Shield of California. In this role, you will be responsible for reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. You will also 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.
Key Responsibilities- Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinical 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
- 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
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