Utilization Management Nurse, Senior

Job Description

Our Facility Compliance Review team reviews post‑service pre‑payment 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. You will also be reviewing hospital itemized bills for a comprehensive line‑by‑line audit and manually processing claims for exceptions to ensure that appropriate billing practices are followed based on facility‑specific contract language.

Exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events, and aberrant billing.

• Perform retrospective utilization reviews and first‑level determination approvals for members using BSC evidence‑based guidelines, policies, and nationally recognized clinical criteria across lines of business or 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 the Medical Director for medical director oversight and necessity determination and communicate determinations to providers and/or members 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 intervene or, as clinically appropriate.
• Clearly communicate, collaborate, and work effectively and efficiently.
• Review itemizations for coding logic using industry standards as well as CMS guidelines.
• Triage and prioritize cases to meet required turnaround times.
• Identify potential quality‑of‑care issues, service or treatment delays as clinically appropriate.
• Apply clinical judgment and detailed knowledge of benefit plans used to complete review decisions.

• Bachelor of Science in Nursing or an advanced degree preferred.
• Current California RN license required.
• At least 5 years of prior relevant experience required.
• Independent motivation, strong work ethic, and strong computer navigation skills required.
• Previous managed care experience including inpatient claims or concurrent review preferred.

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State, and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status, or disability status and any other classification protected by Federal, State, and local laws.