Utilization Management Nurse, Senior (Post-Service Review)

Utilization Management Nurse, Senior (Post-Service Review) at Blue Shield of California summary: The Senior Utilization Management Nurse performs retrospective reviews of outpatient claims to assess medical necessity and compliance with health policies. This role requires extensive knowledge of clinical guidelines and benefits, alongside effective communication with providers and members. The nurse will also identify quality of care issues and prepare cases for oversight by medical directors, ensuring adherence to regulatory standards.

Your Role

The Clinical Post Service team reviews outpatient post service claims with medical records supporting services rendered to members for medical necessity and benefit validation. The Utilization Management Nurse, Senior

will report to the Manager, Utilization and Medical Review. In this role you will be performing post service review for members using BSC evidenced based guidelines, medical policies, and nationally recognized clinical criteria across lines of business. Successful RN candidate reviews post service requests for medical necessity, coding accuracy and medical policy compliance while maintaining turn-around time and production expectations. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required. 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 Commercial

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

Triages and prioritizes cases to meet required turn-around times

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

Your Knowledge and Experience

Bachelors of Science in nursing or advanced degree preferred

Requires a current California RN License

Requires at least 5 years of prior relevant experience

Requires strong attention to detail to include ability to analyze claim data analytics

Requires independent motivation, strong work ethic and strong computer navigations skills

Prior post service 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.

Keywords: Utilization Management, Nurse, Post-Service Review, Medical Necessity, Claims Review, Clinical Judgment, Healthcare Compliance, Nursing, Accreditation Standards, Benefit Plans