Job Summary
With the support of the precertification coordinator, the nurse consultant is primarily responsible for the day-to-day activities of researching, reviewing, processing, and communicating to members and providers involved in precertification of inpatient and outpatient services, prior authorizations, and alternative care requests.

Work Location
This 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

• Independently obtain and conduct reviews for medical necessity and contract eligibility.

• Determine through independent medical knowledge when medical consultant expertise is required. Such determinations must be made under limited and extreme time constraints.

• Responsible for researching, analyzing and/or coordinating unusual or complex requests for services.

• Responsible for identification of potential experimental/investigational or unlabeled use services. Obtain appropriate information to include medical research, consultant input, and/or contractual language changes and pursue to resolution.

• Appropriate application of InterQual medical criteria.

• Appropriate identification and referral of case management situations.

• Performing all activities in compliance with State, URAC, HIPAA, DOL, MTM goals, and CMS guidelines.

• Performing all job functions within the scope of the Kansas Nurse Practice Act.

• Orientation of precertification activities to new employees within the department (Precert, Case Management, Medicare Advantage, etc).

Education

• Associate's degree in Nursing (ADN) required

• Bachelor's degree or equivalent in Nursing, Healthcare, or similar field preferred

Experience

• Minimum 3 years' experience in a clinical nursing role required

• Acute medical/surgical experience preferred

• Previous experience in Precertification/Utilization Management (UM) preferred

Licenses and Certifications

• Current, active, unrestricted Kansas RN License required

Travel

• Minimal travel (0-10%)

Knowledge/Skills/Abilities

• Knowledge of InterQual medical criteria helpful.

• Ability to effectively communicate in writing, verbally, and via telephone about confidential and sensitive issues.

• Ability to self-direct, make independent decisions, and prioritize daily activities.

• Ability to handle sensitive situations in a positive, professional manner.

• Awareness and understanding of current medical care practices.

• Capable of utilizing a personal computer (PC), calculator and telephone.

• Schedule could require alternative work hours, which may include evenings and weekends.

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.