Utilization Management Nurse, Senior

The Facility Compliance Reviewteamreviewspost service prepayment facility claims for contract compliance, industry billing standards, medicalnecessityand hospitalacquiredconditions/neverevents. The Utilization Management Nurse,Seniorwillreport to the Senior Manager, Facility Compliance  thisroleyou will bereviewing medical documentsandapplying clinical criteria toestablishthe most appropriate levelof care.

Also,youwill 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 followedbased on facility specific contract language. These exceptions mayincludemedical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospitalacquiredconditions/never events and aberrant billing.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work

In this role, you will:

• Perform retrospectiveutilizationreviews 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 FEP
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policycomplianceand 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 standardsandidentifypotential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
• Clearly communicates, is collaborative, while working effectively and efficiently
• Review itemizations forcoding logic using industry standards as well as CMS guidelines
• Triages and prioritizes cases to meet required turn-around times
• Identifies potential quality of care issues,serviceor treatment delays as clinically appropriate.
• Clinical judgment and detailed knowledge of benefit plans used to complete review decisions

Your Knowledge and Experience

• Bachelor of Science in Nursing or Advanced degree preferred
• Requires a current California RN License
• Requires at least5years of prior relevant experience
• Requires independent motivation, strong workethic,and strong computer navigations skills
• Previousmanaged careexperienceincludinginpatient claims or concurrent review preferred

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan;
Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies.

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield isa U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair
360 as a Top Regional Company,…