Nurse Consultant

Bcbsks; Topeka (KS); Hybrid; USD 74,000 - 92,000; Full time

Benefits offered by this job

Health insurance

Tuition reimbursement

401(k) plan matching up to 5%

Paid parental leave

Paid caregiver leave

Health & fitness benefits

Job summary

Blue Cross and Blue Shield of Kansas seeks a Nurse Consultant to manage day-to-day predeterminations, claims, and appeals using medical policy and InterQual criteria. You will serve as a clinical resource for staff and providers, ensuring adherence to regulations and cost-effective decision making.

Remote/hybrid/onsite flexibility is available; applicants must reside in Kansas or Missouri or be willing to relocate.

Qualifications

• High school diploma or equivalent required.
• Bachelor's degree in nursing preferred.
• RN licensure with state KS required or equivalent.

Responsibilities

• Review and adjudicate predeterminations, claims, and appeals using medical policy and InterQual criteria.
• Provide clinical support for internal staff and ensure compliance with HIPAA and regulatory guidelines.
• Communicate medical decisions to providers, staff, members, and state agencies as needed.
• Maintain professional accreditations and follow Kansas Nurse Practice Act requirements.

Skills

Analytical background

Self-directed

Effective communication

Prioritization

Problem solving

Team collaboration

Attention to detail

Clinical nursing experience

Education

High school diploma or equivalent

Bachelor's degree in nursing

Job description

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. Paid vacation and sick leave with paid maternity and paternity available immediately upon hire

• Professional Growth Opportunities: Advance your career with ongoing training and development programs.

• Dynamic Work Environment: Collaborate with a team of passionate and driven individuals in a work environment that promotes flexibility.

• Trust and Stability: Work for one of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.

• Inclusive Work Environment: We pride ourselves on fostering a workplace where everyone is valued and respected.

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

Job Summary

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.

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

• 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

Travel

• No travel

Knowledge, 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.

Our Commitment to Connection and Belonging

At Blue Cross and Blue Shield of Kansas, we are committed to fostering a culture of connection and belonging, where mutual respect is at the foundation of our workplace. We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law.

Blue Cross and Blue Shield of Kansas conducts pre-employment drug screening, criminal conviction check, employment verifications and education as part of a conditional offer of employment.