[Hiring] Utilization Management Nurse, Senior @Aditi Consulting

Role Description

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. You will also 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.

• Perform retrospective utilization reviews and first level determination approvals for members using 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 to 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 communicates, is collaborative, while working effectively and efficiently.
• Review itemizations for coding logic using industry standards as well as CMS guidelines.
• Triages and prioritizes cases to meet required turn-around times.
• Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
• Utilizes 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.

Requirements

• The typical base pay for this role across the U.S. is: $48.00 - $50.00/hr.
• Non-exempt positions are eligible for overtime at a rate of 1.5 times the base hourly rate for all hours worked in excess of 40 in a work week, or as required by state or local law.
• Final offer amounts, within the base pay set forth above, are determined by factors including your relevant skills, education and experience.

Benefits

• Medical, dental, and vision benefits.
• Health savings accounts with qualified medical plan enrollment.
• 10 paid days off.
• 3 days paid bereavement leave.
• 401(k) plan participation with employer match.
• Life and disability insurance.
• Commuter benefits.
• Dependent care flexible spending account.
• Accident insurance.
• Critical illness insurance.
• Hospital indemnity insurance.
• Accommodations and reimbursement for work travel.
• Discretionary performance or recognition bonus.
• Sick leave and mobile phone reimbursement provided based on state or local law.