Utilization Management Nurse, Senior

Utilization Management Nurse, Senior at Blue Shield of California summary: The Utilization Management Nurse, Senior is responsible for reviewing post-service prepayment facility claims to ensure compliance with industry standards, medical necessity, and billing practices. This role involves conducting clinical reviews, preparing cases for medical oversight, and collaborating effectively with healthcare providers to resolve billing discrepancies. The nurse utilizes strong analytical skills and industry knowledge to assess claims and identify quality of care issues.

Your Role

The Facility Compliance Review team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events. The Utilization Management Nurse, Senior will report to the Senior Manager, Facility Compliance Review. In this role you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. Also, you will be reviewing hospital itemized bills for a comprehensive line-by-line audit and manual claims processing on exceptions to ensure that appropriate billing practices are followed based on facility specific contract language. These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing. Your Work

In this role, you will:

Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP

Conducts clinical review 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 to 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 intervenes or as clinically appropriate

Clearly communicates, is collaborative, while working effectively and efficiently

Review itemizations for coding logic using industry standards as well as CMS guidelines

Triages and prioritizes cases to meet required turn-around times

Identifies potential quality of care issues, service or treatment delays as clinically appropriate.

Clinical judgment and detailed knowledge of benefit plans used to complete review decisions

Your Knowledge and Experience

Requires Bachelors 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 navigations skills preferred

Arbitration experience preferred

DRG validation review experience preferred

Pay Range:

The pay range for this role is: $ 87230.00 to $ 130900.00 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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Keywords: Utilization Management, Nurse, Medical Review, Billing Compliance, Healthcare, Quality of Care, Clinical Review, Claims Processing, RN License, Healthcare Analytics