Precert Nurse Consultant

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

Mild 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.

Benefits & Perks

• Base compensation is only one component of your competitive Total Rewards package.
• Incentive pay program (EPIP).
• Health/Vision/Dental insurance.
• 6 weeks paid parental leave for new mothers and fathers.
• Fertility/Adoption assistance.
• 2 weeks paid caregiver leave.
• 401(k) plan matching up to 5%.
• Tuition reimbursement.
• Health & fitness benefits, discounts and resources.

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.