Clinical Review Nurse

19 hours ago

Rancho Cordova, California, United States Blue Shield of California Full time
Your Role

The Commercial Post Service Review team at Blue Shield of California is responsible for clinically reviewing claims that are the result of either a preservice or claim denial. As a Senior Clinical Reviewer, you will report to the Manager, Post Service, and perform accurate and timely clinical review of post service claims for the CalPERS population.

The successful candidate will review outpatient post service cases for benefits, medical necessity, coding accuracy, and medical policy compliance, utilizing the Blue Shield of California Medical Policy, Blue Shield of California evidenced-based guidelines, policies, and nationally recognized clinical criteria.

Your Work

In this role, you will:

  • Prepare and submit clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination if needed.
  • Communicate determinations to members and providers in compliance with state, federal, and accreditation requirements.
  • Ensure proper procedure codes and diagnosis codes are reviewed for submitted claims match the services that were performed.
  • Initiate appropriate referrals for members' needs to other departments, such as Case Management, Potential Quality Issues (PQI), etc.
  • Triage and prioritize your caseload to meet required regulatory turn-around times.
Your Knowledge and Experience

To be successful in this role, you will require:

  • A current CA RN License.
  • A Bachelors of Science in Nursing or advanced degree preferred.
  • At least 5 years of prior experience in nursing, healthcare, or other related fields.
  • Knowledge of the insurance industry and benefit reviews preferred.
  • Knowledge of CPT-4, ICD-9, HCPCs, with 1-2 years' experience in coding.
  • Knowledge of hospital billing patterns, Charge Master descriptions, and contract language.
  • Strong analytical and problem-solving skills.
  • Advanced knowledge of job area typically obtained through advanced education combined with experience.
  • Experience in MediCare and MediCal, preferred.

Pay Range:

The pay range for this role is: $ 87,230.00 to $ 130,900.00 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.

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