Nurse Consultant

Blue Cross Blue Shield of Kansas • Topeka, KS • 1d ago

This job was posted by https://www.kansasworks.com : For more information, please see: https://www.kansasworks.com/jobs/13467048 This position is responsible for the day-to-day operations of reviewing and processing predeterminations, claims, appeals, and other inquiries utilizing independent decision making in accordance with medical policy, standards of medical practice, and within contractual benefits. Must be able to communicate these decisions to internal staff and to providers, members, and the Kansas Insurance Department (via CSC) as needed. The Nurse Consultant will serve as a primary resource for internal staff throughout the company regarding medical policy, correct coding, medical necessity, and other processes that relate to claims adjudication, cost effectiveness, and predeterminations. Responsible for performing all activities within state, HIPAA, DOL, InterQual, and MTM goals or guidelines.

\"This position is eligible to work onsite, remote or hybrid (9 or more days a month on site) in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.\"

**Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.

Why Join Us**

Make a Positive Impact: Your work will directly contribute to

the health and well-being of Kansans.

Family Comes First: Total rewards package that promotes the

idea of family first for all employees.

Dynamic Work Environment: Collaborate with a team of passionate

and driven individuals.

Trust: Work for one of the most trusted companies in Kansas

Stability: 80 years of commitment, compassion and community

Compensation

\$73,920 - \$92,400 annually

Exempt 15

Blue Cross and Blue Shield of Kansas offers excellent competitive

compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual\'s skills, education, experience, and training. The range may vary above or below the stated amounts.

What you\'ll do

Responsible for independent timely resolution of predeterminations,

claims, and appeals utilizing medical policy/Interqual criteria and/or physician consultant recommendations as needed.

Responsible for responding to inquiries regarding medical necessity,

correct coding, allowances, audits/CSC requests, and coding assistance requests throughout the company.

Responsible for providing clinical support for MR analysts and other

internal staff as needed.

Responsible for performing all job functions within the scope of the

Kansas Nurse Practice Act and maintaining professional accreditations as appropriate to the position.

Responsible for identifying potential quality of care issues and

making appropriate referrals. Assists with gathering of quality assurance/utilization management data, problem identification and analysis of data. This includes development of criteria and guidelines.

Responsible for maintaining strict HIPPA confidentiality.

Routinely provide decisions that set precedent and place the company

at financial risk for shield claims and cross claims up to \$500,000.

May be responsible for attending, participating in, and leading

special projects and meetings.

Must follow current URAC standards as required for essential job

functions.

What you need

Knowledge/Skills/Abilities

Must have a strong analytical background.

Must be self-directed with the ability to make independent decisions

and prioritize personal production activities.

Must be able to maintain a productive and professional relationship

with internal teams and external cross departmental and divisional teams.

Ability to communicate effectively, verbally, in writing, and via

telephone regarding sensitive and confidential issues while maintaining a professional image.

Ability to assess, problem solve, analyze, plan, and evaluate

situations using critical thinking skills, reasoning, and research.

Ability to handle sensitive situations in a positive, professional

manner.

Education and Experience

High School diploma or equivalent required. Baccalaureate in nursing

preferred.

Current unrestricted Kansas RN licensure required.

Minimum 3 years of clinical nursing experience - required.

RN experience in Surgical, Medical, Obstetric, and/or Utilization

Management preferred.

CPC certified or obtain certification by American Academy of

Professional Coders within three years of hire.

Physical Requirements

90-100% sedentary work setting usi

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