Senior Utilization Management Nurse
1 day ago
We are seeking a highly skilled Senior Utilization Management Nurse to join our team at Blue Shield of California. As a key member of our Facility Compliance Review team, you will play a critical role in reviewing post-service prepayment facility claims for contract compliance, industry billing standards, medical necessity, and hospital-acquired conditions/never events.
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.
- Conduct clinical reviews 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 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 intervene as clinically appropriate.
- Clearly communicate, collaborate, and work effectively and efficiently.
- Review itemizations for coding logic using industry standards as well as CMS guidelines.
- Triage and prioritize cases to meet required turn-around times.
- Identify potential quality of care issues, service or treatment delays as clinically appropriate.
- Requires a Bachelor's 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 navigation skills preferred.
- Arbitration experience preferred.
- DRG validation review experience preferred.
Blue Shield of California offers a competitive salary range of $87,230.00 to $130,900.00 for California. We are committed to making work-life balance a reality and offer a hybrid work model that allows you to decide where you can do your best and most meaningful work.
We are an equal employment opportunity employer and welcome applications from diverse candidates. Please note that external hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State, and local laws.
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Utilization Management Nurse, Senior
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