Utilization Management Nurse, Senior

Your RoleThe 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 WorkIn this role, you will: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 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 communicate, collaborate, 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.Identify potential quality of care issues, service or treatment delays as clinically appropriate.Utilize clinical judgment and detailed knowledge of benefit plans to complete review decisions.Your Knowledge and ExperienceRequires 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, e.g., 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 navigational skills preferred.Arbitration experience preferred.DRG validation review experience 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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