Utilization Management Nurse, Senior (Behavioral Health Post-Service Review)

Your Role

The Commercial Post Service Review team is responsible for clinically reviewing claims that are the result of a claim denial. The Commercial Post Service Review RN will report to the Manager, Post Service. In this role you will perform accurate and timely clinical review of post service claims focused primarily on Behavioral Health outpatient services, Partial Hospitalization Program (PHP) and Intensive Outpatient Program (IOP). The RNs perform reviews utilizing the Blue Shield of California Medical Policy, Blue Shield of California evidenced based guidelines, policies, and nationally recognized clinical criteria. The successful RN candidate will review outpatient post service cases for benefits, medical necessity, coding accuracy and medical policy compliance.

Your Knowledge and Experience

• Requires a current CA RN License.
• Bachelor of Science in Nursing or advanced degree preferred.
• Requires at least 5 years of prior experience in nursing, healthcare or other related fields.
• Knowledge of the insurance industry and benefit reviews preferred.
• Knowledge of CPT-4, ICD-9, HCPCs, with 1-2 years' experience in coding.
• Psych claims review experience preferred.
• Previous Inpatient Psych experience preferred
• Strong analytical and problem-solving skills.
• Requires advanced knowledge of job area typically obtained through education combined with experience.