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 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