The Senior Utilization Management Nurse reviews facility claims for contract compliance, billing accuracy, medical necessity, and hospital-acquired conditions. This role reviews medical records and applies clinical criteria to determine the appropriate level of care. The position also conducts detailed, line-by-line audits of hospital bills and processes claim exceptions according to facility-specific contract requirements.
Responsibilities
Perform retrospective utilization reviews and first-level determinations using evidence-based guidelines, policies, and nationally recognized clinical criteria.
Conduct clinical reviews of claims for medical necessity, coding accuracy, medical policy compliance, and contract compliance.
Prepare and present cases to the Medical Director for oversight and medical necessity determinations.
Communicate determinations to providers and members in compliance with applicable regulatory and accreditation requirements.
Prepare and review member-centered documentation and correspondence reflecting clinical determinations.
Identify potential quality-of-care issues, treatment delays, and service concerns, and intervene when clinically appropriate.
Review itemized hospital bills for coding accuracy and billing logic using industry standards and applicable regulatory guidelines.
Audit claims involving medical necessity, diagnosis-related groups, stop-loss provisions, trauma, emergency services, burns, implants, neonatal intensive care, transplants, hospital-acquired conditions, and unusual billing patterns.
Triage and prioritize cases to meet required turnaround times.
Apply clinical judgment and detailed knowledge of benefit plans to support review decisions.
Communicate clearly and collaborate effectively while maintaining efficiency and accuracy.
Requirements
Current California Registered Nurse license.
At least five years of relevant professional experience.
Strong computer navigation and documentation skills.
Ability to work independently with strong motivation and work ethic.
Managed care experience, including inpatient claims or concurrent review, preferred.
Skill
Utilization management and retrospective clinical review
Medical necessity and level-of-care determination
Claims auditing and coding accuracy review
Contract and regulatory compliance
Clinical documentation and case presentation
Knowledge of benefit plans and clinical guidelines
Prioritization, communication, and collaboration
Summary Qualification
Licensed Registered Nurse in California with at least five years of relevant experience.
Experience reviewing medical records, hospital claims, itemized bills, and clinical documentation.
Knowledge of medical necessity criteria, coding standards, benefit plans, and managed care processes.
Strong independent judgment, attention to detail, communication skills, and computer proficiency.
Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.
Numbers & Facts
Location
El Dorado Hills, CA
Skills
Auditingunmatched
Billingunmatched
Clinical Practices/Protocolsunmatched
Clinical Study Publicationsunmatched
Clinical Validationunmatched
Code Reviewsunmatched
Coding Standardsunmatched
Communication Skillsunmatched
Compensation and Benefitsunmatched
Computer Skillsunmatched
Detail Orientedunmatched
Diagnosis-Related Group (DRG)unmatched
Documentationunmatched
Emergency Servicesunmatched
Establish Prioritiesunmatched
Hospitalunmatched
Implantsunmatched
Industry Standardsunmatched
Legalunmatched
Managed Careunmatched
Medical Billingunmatched
Medical Codingunmatched
Medical Diagnosisunmatched
Medical Recordsunmatched
Neonatal Intensive Care Unit (NICU)unmatched
Nursingunmatched
Patient Careunmatched
Patient Care Authorizationsunmatched
Process Managementunmatched
Quality of Careunmatched
Registered Nurse (RN)unmatched
Regulationsunmatched
Regulatory Complianceunmatched
Utilization Managementunmatched
🎯
Be found by employers
5,500+ employers search our resume database daily. Add yours to get found by recruiters looking for candidates like you.
Level up your application
Professional resume templates
Browse dozens of recruiter approved resume templates, layouts and formats. Choose your favorite and make it your own in minutes.