Job Posting for Claims Clinical Review Nurse, Senior at Blue Shield of California
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 current California RN License
Requires 5 years of relevant experience
Typically, requires a college degree or equivalent experience and 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
Pay Range:
The pay range for this role is: $ 87230.00 to $ 130900.00 for California.
Note:
Please note that this range represents the pay range for this and many other positions at Blue Shield that fall into this pay grade. Blue Shield salaries are based on a variety of factors, including the candidate's experience, location (California, Bay area, or outside California), and current employee salaries for similar roles.
About the Company: Blue Shield of California
Salary.com Estimation for Claims Clinical Review Nurse, Senior in El Dorado Hills, CA
$104,863 to $139,599
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