Job Information
Blue Cross Blue Shield of Kansas Nurse Consultant in Wichita, Kansas
This job was posted by https://www.kansasworks.com : For more information, please see: https://www.kansasworks.com/jobs/12920065
::: {aria-hidden="true"} Job Description Summary :::
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::: {title="" automation-id="multilineTextView" metadata-id="56$146082" uxi-form-item-child-list-index="22" aria-labelledby="56$146082--uid1709-formLabel"} ::: {dir="ltr"} 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 remote, 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. :::
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::: {dir="ltr"} 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.
Stability: 80 years of commitment, compassion and community
Flexibility: options to work onsite, hybrid or remote available
Balance: paid vacation and sick leave with paid maternity and paternity available immediately upon hire
Inclusive Work Environment: We pride ourselves on fostering a diverse and inclusive workplace where everyone is valued and respected.\
Compensation
\$69,760 - \$83,000 annually
- Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The hourly 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 salaries that align with the individual\'s skills, education, experience, and training. The range may vary above or below the stated amounts.
What youll 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 tha t set precedent and place the company at financial risk for shield claims and cross claims up to \$500,000.
Must follow current URAC standards as required for essential job functions.
What you need
Current unrestricted Kansas RN licensure ::: :::
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