Utilization Management Nurse, Senior

Your Role

The FEP Post Service (PS-CR) department is BSC Federal Employee Program (FEP) retrospective clinical review program that entails detailed claims review of billed physician services and related outpatient facility services against FEP medical benefit and/or payment policy. The Post Service Clinical Review nurse will report to the manager of FEP Post Services. In this role you will be  reviewing claims and medical records review of services rendered to FEP members. Post-Service Clinical Nurse reviews for medical necessity, medical policy, benefits, and clinical coding. Post-Service Clinical Review is accountable for the initial review process through the final appeal as dictated by FEP policy. Post-Service Clinical Review works in coordination with other claims and appeals departments to ensure providers are paid appropriately and members receive quality care.

Your Work

• In this role, you will:
• Perform clinical claim reviews and first claim level determination approvals for members using FEP evidenced based guidelines, policies and nationally recognized clinal criteria
• 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 medical necessity determination and communicate determinations to providers and/or members in compliance with federal and accreditation requirements
• Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards
• Triages and prioritizes cases to meet required turn-around times
• Identifies potential quality of care issues, service or treatment delays and intervenes or as clinically appropriate
• Provides referrals to Case Management, Disease Management, Appeals and Grievance and Quality Departments as necessary
• Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.
• Other duties as assigned.

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
• Prior relevant experience In Post Service/Claims Review, Prior Auth Experience or Outpatient Claims Experience
• Knowledge of CPT, ICD-10, HCPCs and provider billing practices
• Demonstrate the ability to act independently using sound clinical judgement
• Experience in a fast paced, production and quality environment preferred
• Demonstrated efficient, time management techniques and skills
• Able to handle multiple tasks simultaneously while prioritizing cases to meet regulatory and business based turnaround times