Job SummaryThis 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.
Work LocationThis position is eligible to work remotely, hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.
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.
Education- High school diploma or equivalent required
- Bachelor's degree or equivalent in nursing preferred
Experience- Minimum 3 years' experience of clinical nursing experience required
- RN experience in Surgical, Medical, Obstetric, and/or Utilization Management preferred
Licenses and Certifications- Current unrestricted Kansas RN licensure required
- CPC certified or obtain certification by American Academy of Professional Coders within three years of hire required
TravelKnowledge, Skills and 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.
Compensation$73,920 - $92,400 annually
Exempt Grade 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.
