Your Role

The Clinical Post Service team reviews outpatient post service claims with medical records supporting services rendered to members for medical necessity and benefit validation. The Utilization Management Nurse, Senior will report to the Manager, Utilization and Medical Review. In this role you will be performing post service review for members using BSC evidenced based guidelines, medical policies, and nationally recognized clinical criteria across lines of business. Successful RN candidate reviews post service requests for medical necessity, coding accuracy and medical policy compliance while maintaining turn-around time and production expectations. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required.

Your Knowledge and Experience

• Bachelors of Science in nursing or advanced degree preferred
• Requires a current California RN License
• Requires at least 5 years of prior relevant experience
• Requires strong attention to detail to include ability to analyze claim data analytics
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Prior post service review experience preferred

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.