Clinical Review Nurse (RN)

Duration 8+ months (can extend or HIRE)

Day to Day Responsibilities of this Position and Description of Project:

mission is to ensure all Californians have access to high-quality health care at a sustainably affordable price. We are transforming health care in a way that truly serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience.

To fulfill our mission, we must ensure a diverse, equitable, and inclusive environment where all employees can be their authentic selves and fully contribute to meet the needs of the multifaceted communities we serve. Our comprehensive approach to DE&I combines a focus on our people processes and systems with a deep commitment to promoting social justice and health equity through our products, business practices, and presence as a corporate citizen.
has received awards and recognition for being a certified Great Place to Work, best place to work for LGBTQ equality, leading disability employer, one of the best companies for women to advance, Bay Area’s top companies in volunteering & giving, and one of the world’s most ethical companies. Here we are striving to make a positive change across our industry and the communities we live in – join us!

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 Work

In this role, you will:

• Perform 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
• Conducts clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance
• Ensure discharge(DC) planning at levels of care appropriate for the members needs and acuity and determine post-acute needs of member including levels of care, durable medical equipment, and post service needs to ensure quality and cost-appropriate DC planning
• 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

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

Our Values

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short.
• Human. We strive to be our authentic selves, listening and communicating effectively, and showing empathy towards others by walking in their shoes.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals.

Posted by CP

Job Types: Full-time, Contract

Pay: $48.00 - $54.00 per hour

Benefits:

• 401(k)
• Dental insurance
• Disability insurance
• Health insurance
• Life insurance
• Vision insurance

Physical setting:

• Office

Schedule:

• 8 hour shift
• Monday to Friday

Education:

• Associate (Required)

Experience:

• clinical review: 3 years (Required)

License/Certification:

• RN (Required)

Work Location: Remote

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