Utilization Review Nurse

About This Role

This Utilization Review Nurse position is for a Registered Nurse on the Facility Compliance Review team, focusing on post-service prepayment facility claims. The role involves reviewing medical documents, applying clinical criteria to determine appropriate care levels, and auditing hospital itemized bills for contract compliance and billing standards. The nurse will also process manual claims for exceptions, ensuring proper billing practices based on facility-specific contract language.

Responsibilities

• Perform retrospective utilization reviews and first-level determination approvals for members using evidenced-based guidelines, policies, and nationally recognized clinical criteria
• Conduct clinical review of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance
• Prepare and present cases to Medical Director (MD) for medical director oversight and necessity determination
• Communicate determinations to providers and/or members 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
• Identify potential quality of care issues, service or treatment delays, and intervene as clinically appropriate
• Clearly communicate and collaborate effectively and efficiently
• Review itemizations for coding logic using industry standards as well as CMS guidelines
• Triage and prioritize cases to meet required turn-around times
• Identify potential quality of care issues, service or treatment delays as clinically appropriate
• Use clinical judgment and detailed knowledge of benefit plans to complete review decisions

Requirements

• Current California RN License
• At least 5 years of prior relevant experience
• Independent motivation, strong work ethic, and strong computer navigation skills
• Previous managed care experience including inpatient claims or concurrent review preferred
• Previous UM/Managed Care Experience
• Concurrent or post-service inpatient review experience
• Bachelor's degree or equivalent experience
• Previous EMR experience preferred
• Microsoft Office including Teams, Outlook

Important Details

• Working Shift: 08:00 AM - 05:00 PM
• Contract: 6+ Months

About the Company

At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.