Utilization Management Nurse, Senior

4 weeks ago


Los Angeles, United States Blue Shield of California Full time

Your Role

The Commercial Post Service Review team is responsible for clinically reviewing claims that are the result of either a preservice or claim denial. The Commercial Post Service Review RN will report to the Manager, Post Service. In this role you will perform accurate and timely clinical review of post service claims. The RNs perform reviews utilizing the Blue Shield of California Medical Policy, Blue Shield of California evidenced based guidelines, policies, and nationally recognized clinical criteria. The successful RN candidate will review both outpatient post service cases for benefits, medical necessity, coding accuracy and medical policy compliance..

Your Work

In this role, you will:

Prepares and submits clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination if needed Communicates determinations to the members and providers in compliance with state, federal and accreditation requirements Ensures proper procedure codes and diagnosis codes are reviewed for submitted claims match the services that were performed Initiates appropriate referrals for member’s needs to other departments such as Case Management, Potential Quality Issues (PQI), etc. Triages and prioritizes their caseload to meet required regulatory turn-around times

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