Clinical Review Specialist
7 days ago
The Facility Compliance Review team at Blue Shield of CA 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. Your key responsibilities will include reviewing medical documents and applying clinical criteria to establish the most appropriate level of care.
Your 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.
We require a Bachelor's of Science in Nursing or an advanced degree. A current California RN License is also necessary. Typically, we require a college degree or equivalent experience and a minimum of 5 years of prior relevant experience. Advanced knowledge of the job area, typically obtained through advanced education combined with experience, is also required. May have practical knowledge of project management. Strong written and oral communication skills, analytical and problem-solving skills, and active AAPC or ADHIMA coding certification, such as CPC-CIC or COC with procedure coding experience (HCPCS/CPT), are preferred. Strong attention to detail, including the ability to analyze claim data analytics, is also preferred. Independent motivation, a strong work ethic, and strong computer navigation skills are also preferred. Arbitration experience and DRG validation review experience are also preferred.
The pay range for this role is $ to $ for California. 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.
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