Utilization Management Nurse, Senior CalPERS (Post-Service)

United States, California, Woodland Hills

Oct 20, 2024

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:

• Prepare and submit clinical case reviews to the Medical Director (MD) for MD collaboration and medical necessity determination if needed.
• Communicate determinations to the members and providers in compliance with state, federal, and accreditation requirements.
• Ensure proper procedure codes and diagnosis codes are reviewed for submitted claims that match the services that were performed.
• Initiate appropriate referrals for member's needs to other departments such as Case Management, Potential Quality Issues (PQI), etc.
• Triaging and prioritizing your caseload to meet required regulatory turnaround times.

Your Knowledge and Experience

• Requires a current CA RN License.
• Bachelor 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 of 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: $87,230.00 to $130,900.00 for California.