ICR- Facility Nurse Reviewer job Rancho Cordova California
ICR- Facility Nurse Reviewer job Rancho Cordova California
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ICR- Facility Nurse Reviewer Job

Employer Name: SpiderID: 13011376
Location: Rancho Cordova, California Date Posted: 11/24/2022
Wage: Negotiable Category: Insurance
Job Code: 17002D9-2191

Job Description:
Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California's Mission is to ensure all Californians have access to high-quality care at an affordable price. Blue Shield is focused on improving health care delivery by working closely with providers and making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 4 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than $325 million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution.

We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.


Working with complex post service facility claims promotes the delivery of quality; cost-effective health care services based on medical necessity, contractual benefits and contract billing compliance. Works with other members of the MCS team, provider relations, hospitals, IPA/MGs, to review utilization review, case management, contract compliance, medical necessity, intensity of services, level of care, length of stay and general appropriateness of care.


  • Performs in-depth facility claim review for appropriate billing, quality, contract compliance and medical necessity

  • Applies accurately Medical Policies and guidelines

  • Preps claim and medical records electronically for Medical Director review

  • Researches contract language and updates tools as needed with the team

  • Participates in team meetings, team building activities and team problem solving

  • May be a lead for special projects/committees/guideline updates.

  • Writes and Formats appeal letter results

  • Meet production timelines individually and turnaround times for regulatory requirements



  • 4-7 years of Hospital experience working as a nurse or Utilization Management.

  • Current Active California RN License Required

  • Generally, requires Bachelor's degree or equivalent work experience

  • Knowledge of Uniform Bill and coding desirable

  • Knowledge of Interqual or Careweb criteria for level of care desirable

  • Strong computer skills, verbal and written communication skills required

  • Ability to multitask using two computer monitors and multiple applications required

Job Criteria:
Start Date:
Position Type: Full-Time Permanent
Years of Experience Required:
Education Required:
Overnight Travel:
Vacation Time:

Contact Information:
Contact Name: Blue Shield of California Company Type:
Company: Blue Shield of California

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