Your Role

The Facility Compliance Review team reviews post service prepayment 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. Also, you will 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 followed based on facility specific contract language. These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing.

Your Knowledge and Experience

• Requires Bachelors of Science in Nursing or advanced degree preferred
• Requires a current California RN License
• Typically, requires a college degree or equivalent experience and minimum 5 years of prior relevant experience
• Typically, requires advanced knowledge of job area typically obtained through advanced education combined with experience. May have practical knowledge of project management
• Requires strong written and oral communication skills
• Requires strong analytical and problem solving skills
• Active AAPC or ADHIMA coding certification, eg CPC-CIC or COC with procedure coding experience (HCPCS/CPT) preferred
• Strong attention to detail to include ability to analyze claim data analytics preferred
• Independent motivation, strong work ethic and strong computer navigations skills preferred
• Arbitration experience preferred
• DRG validation review experience 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.

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