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 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.