Utilization Management Nurse, Senior - Blue Shield of California : Job Details

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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 reports to the Senior Manager, Facility Compliance Review. In this role, you will review medical documents and apply clinical criteria to establish the most appropriate level of care, focusing primarily on inpatient psych reviews for Residential Treatment and Detox. You will also review hospital itemized bills for comprehensive line-by-line audits and manual claims processing on exceptions to ensure proper billing practices based on facility-specific contract language. Exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events, and aberrant billing.