Utilization Management Nurse, Senior CalPERS (Post-Service) at Blue Shield of California

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 for the CalPERS population.  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 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

Your Knowledge and Experience

• Requires a current CA RN License.
• Bachelors of Science in Nursing or advanced degree preferred.
• Requires 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.
• Requires 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: $ 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.