Pre-Service Clinical Review RN - Ensures accurate and timely prior authorization of designated healthcare services and timely and accurate clinical claim review of designated healthcare services. The Pre-Service Clinical Review RN performs first level determination approvals for members using BSC evidenced based guidelines, policies and nationally recognized clinical criteria across lines of business or for a specific line of business such as Medicare. Successful RN candidate reviews prior auth requests for medical necessity, coding accuracy and medical policy compliance. Clinical judgment and detailed knowledge of benefit plans used to complete review decisions is required.
Ensures proper procedure and diagnosis codes is reviewed for submitted procedures/claims.
Solicits support from SME's, leads and managers as appropriate.
Triages and prioritizes cases to meet required turn-around times.
Expedites access to appropriate care for members with urgent needs.
Prepares and submits clinical review 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.
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.
Knowledge & Experience
Current CA RN License.
Bachelors 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.
About Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!
EEO Footer: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.