Compliance Nurse Lead

3 weeks ago


Oakland, California, United States Blue Shield of CA Full time

The Utilization Management Nurse, Senior plays a critical role in reviewing medical documents and applying clinical criteria to ensure post-service prepayment facility claims comply with contract requirements and industry standards. This position requires a unique blend of clinical expertise and analytical skills.

Responsibilities

  • Review medical documents and apply clinical criteria for determining suitable level of care
  • Audit hospital itemized bills for comprehensive line-by-line reviews
  • Manual claims processing on exceptions

Requirements

  • Bachelor's of Science in Nursing or advanced degree
  • Current California RN License
  • Typically 5+ years of relevant experience and college degree or equivalent
  • Active AAPC or ADHIMA coding certification (e.g., CPC-CIC or COC) with procedure coding experience (HCPCS/CPT)

Salary Range:

$87,230.00 - $130,900.00 per year, depending on location and experience.


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