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Post Service Review Intermediate - 33298-1
601 Potrero Grande Drive Monterey Park, CA 91755 | Contract
CA LVN/Utilization Review Specialist
Performs advanced or complicated post service; pre-payment and retrospective case review, determines that appropriate care has been rendered during inpatient, outpatient and/or ancillary services. The review process requires interpretation and application of evidenced based criteria. Clinical judgment and detailed knowledge of benefit plans are used to complete review decisions. Ultimate goal is that the appropriate care has been delivered to the member and that the provider and facility has billed the services correctly through use of Medical Policy, Correct CPT coding, nationally recognized evidence based criteria and facility contract adherence.
Performs clinical review and provides approval determination for members using BSC evidenced based guidelines, policies and nationally recognized clinical criteria across lines of business. Ensures diagnosis matches ICD-9 codes. Conduct review activities with delegated entities as necessary and member treatment in order to meet BSC Medical Policy, Contract Compliance for Stop Loss and Disallowed charges and appropriate delivery of care at the provider level as measured against their peer group.
Validate appropriate level of care and services provided to meet the members needs at the appropriate place of service.
Prepares and present cases to Medical Director (MD) as required by law for medical necessity determination. Identifies potential over-payments. CISD reviews claims for Provider on review. PCR reviews claims for Provider Compliance. FCR reviews claims for Facility Compliance
Assists in the development and implementation of a proactive approach to improve and standardize overall retro claims review for clinical perspectives.
Identifies potential quality of care issues, service or treatment delays. Provides referrals to Quality Departments as necessary.
Identifies possible fraud and abuse, documents billing errors and saving opportunities. Collaborates with Special Investigations Unit and Legal Department as necessary.
Conducts retrospective clinical review of claims for medical necessity, coding accuracy, medical policy compliance and contract compliance. Current CA RN License. Bachelors or advanced degree preferred
Ability to perform critical in-depth analysis of medical records for appropriateness of care and level of care.
Developing knowledge of claims processing and coding as defined by the AMA - expectation is up to two years to comprehend fully.
Extensive knowledge of specialty areas of clinical practice.
Maintains and updates knowledge to be informed regarding billing and payment legislation and complies with all regulations related to review and payment logic.
Generally requires moderate to thorough experience in nursing, health care or related field. (3-5 years).
Preferably with concentration of clinical expertise in a defined specialty or utilization review experience.
Preferably with clinical expertise in hospital practices with charges and billing procedures.
BS sponsors membership to American Association of Medical Audit Specialists. Must participate and prepare for certification exam within two years of employment.