Utilization Management Nurse, Senior CalPERS

Your Role Utilization and Medical Review - Ensures accurate and timely prior authorization of designated healthcare services, concurrent review activity, and retrospective review activity. Utilization Management Nurse - Performs prospective, concurrent and retrospective utilization reviews and first level determination approvals for members using BSC evidence- based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business, such as Medicare and FEP. Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions.  Your Work In this role, you will: Performs prospective, concurrent, and retrospective utilization reviews and first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinal criteria across lines of business or for a specific line of business such as Medicare and FEP. Reviews for medical necessity, coding accuracy, medical policy compliance and contract compliance. Ensures diagnosis matches ICD10 codes. Solicits support from SME's, leads and managers as appropriate. Participates in huddles/ team meetings. Conduct UM review activities for appropriate member treatment to meet Recommended Length of Stay based on medical necessity criteria. Ensures discharge (DC) planning at levels of care appropriate for the members needs and acuity. Determines post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning. Triages and prioritizes cases to meet required turn-around times. Expedites access to appropriate care for members with urgent needs. Prepares and presents cases to Medical Director (MD) for medical director oversight and necessity determination. Communicate determinations to providers and/or members to in compliance with state, federal and accreditation requirements. Develops and reviews member centered documentation and correspondence reflecting determinations in compliance with regulatory and accreditation standards. 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. Identifies potential over-payments: - CISD reviews claims for Medical Necessity for Providers - FCR reviews claim for Facility Compliance Identifies potential Third-Party Liability and Coordination of Benefit cases and notifies appropriate internal departments. 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 Current CA RN License. Bachelor of Science in Nursing or advanced degree preferred. Requires practical knowledge of job area typically obtained through advanced education combined with experience. Typically, requires a college degree or equivalent experience and 5 years of prior relevant experience. Post Service Review Specific requirements: Knowledge of CPT-4, ICD-9, HCPCs, with minimum of 1 year of experience in coding. Knowledge of hospital billing patterns, Charge Master descriptions, and contract language.

Created: 2025-03-01