What are the responsibilities and job description for the Utilization Management Nurse, Senior CalPERS position at Blue Shield of CA?
Your Role
Utilization and Medical Review - Ensures accurate and timely prior authorization of designated healthcare services, concurrent review activity, and retrospective review activity. Utilization Management Nurse - Performs prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidence- based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business, such as Medicare and FEP. Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions.
Your Knowledge and Experience
- Current CA RN License.
- Bachelor of Science in Nursing or advanced degree preferred.
- Requires practical knowledge of job area typically obtained through advanced education combined with experience.
- Typically, requires a college degree or equivalent experience and 5 years of prior relevant experience.
- Post Service Review Specific requirements: Knowledge of CPT-4, ICD-9, HCPCs, with minimum of 1 year of experience in coding.
- Knowledge of hospital billing patterns, Charge Master descriptions, and contract language.
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 regards 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.
