Utilization Management Nurse, Senior

Company: Blue Shield of California
Location: Santa Ana
Posted on: June 24, 2025

Job Description:

Your Role The Facility Compliance Review (FCR) 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. This role will be focusing primarily on inpatient psych reviews for Residential Treatment and Detox. 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 Work In this role, you will: Perform retrospective utilization reviews 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 policy compliance and 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 standards and identify potential 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 for coding 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, service or treatment delays as clinically appropriate. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions Your Knowledge and Experience Requires a bachelor's degree or equivalent experience Requires a current California RN License Requires at least 5 years of prior relevant experience Previous Inpatient Psych experience preferred Requires strong attention to detail to include ability to analyze claim data analytics Requires independent motivation, strong work ethic and strong computer navigations skills Psych claims review experience preferred

Keywords: Blue Shield of California, Vista , Utilization Management Nurse, Senior, Healthcare , Santa Ana, California