Medical Review 3

Description: Summary:
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 Work

• Perform retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare and FEP.
• Conduct 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 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 communicate, collaborate, while working effectively and efficiently.
• Review itemizations for coding logic using industry standards as well as CMS guidelines.
• Triage and prioritize cases to meet required turn-around times.
• Identify potential quality of care issues, service or treatment delays as clinically appropriate.
• Use clinical judgment and detailed knowledge of benefit plans to complete review decisions.
  

Qualifications:

• Requires a current California RN License.
• Requires at least 5 years of prior relevant experience.
• Requires independent motivation, strong work ethic and strong computer navigation skills.
• Previous managed care experience including inpatient claims or concurrent review preferred.
  

Additional Information:

• Interview Process: Schedule for interview for 30 minutes to discuss the role and their experience.
• Potential to Convert to FTE: Yes, if funding is secured it could be turned into FTE.
• Software Skills Required: Previous EMR experience preferred, Microsoft Office including Teams, Outlook.
• Interview Method: Video Interview.
• Travel Required: No.
• Would you be open to hiring workers outside of California in lower cost markets? No.
• Number of Interviews: 1.
• Who will conduct interviews: Anna Gunsser and Tara Brown.
• Required Testing: No.
• Top 3 Required Skills: Previous UM/Managed Care Experience, Concurrent or post service inpatient review experience, CA RN Licensure.
• Required Certifications: CA RN Licensure.
• Education Requirements: Requires a bachelor's degree or equivalent experience, Requires a current California RN License, Requires at least 5 years of prior relevant experience.
• Work Set up: Remote.
• Will this worker be supporting HMO or PPO? PPO.