Utilization Review Nurse

The Facility Compliance Review team reviews post service prepayment facility claims for contract compliance, industry billing standards, medical necessity and hospital acquired conditions/never events.. The Utilization Management Nurse, Senior will report to the Senior Manager, Facility Compliance Review. In this role you will be reviewing medical documents and applying clinical criteria to establish the most appropriate level of care. Also, you will be reviewing hospital itemized bills for a comprehensive line-by-line audit and manual claims processing on exceptions to ensure that appropriate billing practices are followed based on facility specific contract language.

These exceptions may include medical necessity, DRG validation, stop loss, trauma, ER, burns, implants, NICU, transplants, hospital acquired conditions/never events and aberrant billing

• Perform retrospective utilization reviews and first level determination approvals for members using client's 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
• 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
• Clearly communicates, is collaborative, while working effectively and efficiently
• Review itemizations for coding logic using industry standards as well as CMS guidelines
• Triages and prioritizes cases to meet required turn-around times
• Identifies potential quality of care issues, service or treatment delays as clinically appropriate.
• Clinical judgment and detailed knowledge of benefit plans used to complete review decisions

• Requires a current California RN License
• Requires at least 5 years of prior relevant experience
• Requires independent motivation, strong work ethic and strong computer navigations skills
• Previous managed care experience including inpatient claims or concurrent review preferred

Previous UM/Managed Care Experience, Concurrent or post service inpatient review experience, CA RN Licensure

• Requires independent motivation, strong work ethic and strong computer navigations skills
• Previous managed care experience including inpatient claims or concurrent review preferred

• Requires a bachelor's degree or equivalent experience
• Requires a current California RN License
• Requires at least 5 years of prior relevant experience

• Requires independent motivation, strong work ethic and strong computer navigations skills
• Previous EMR experience preferred
• Microsoft Office including Teams, Outlook

CA RN Licensure

• For information on benefits, equal opportunity employment, and location-specific applicant notices,

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.

This position's pay range is $40.00/hr - $50.00/hr.