Nurse Consultant

Blue Cross and Blue Shield of Kansas; Topeka (KS); Hybrid; USD 80,000 - 110,000; Full time

Benefits offered by this job

Incentive pay program (EPIP)

Health/Vision/Dental insurance

6 weeks paid parental leave for new a/

Fertility/Adoption assistance

2 weeks paid caregiver leave

401(k) plan matching up to 5%

Tuition reimbursement

Health & fitness benefits, discounts

Job summary

Blue Cross and Blue Shield of Kansas seeks a Nurse Consultant to oversee predeterminations, claims, and appeals, applying medical policy and InterQual criteria to guide independent decisions.

This role serves as a clinical resource for staff, providers, and the Kansas Insurance Department, ensuring correct coding, medical necessity determinations, and cost-effectiveness. Remote/hybrid/onsite options available; KS/MO residency or relocation required.

Qualifications

• Minimum 3 years' clinical nursing experience.
• RN experience in Surgical, Medical, Obstetric, and/or Utilization Management preferred.
• Current unrestricted Kansas RN licensure required.
• CPC certification within three years of hire required.

Responsibilities

• Independent timely resolution of predeterminations, claims, and appeals using medical policy/Interqual criteria and physician consultant recommendations as needed.
• Respond to inquiries regarding medical necessity, correct coding, allowances, audits/CSC requests, and coding assistance.
• Provide clinical support for MR analysts and other internal staff as needed.
• Perform all job functions within the Kansas Nurse Practice Act and maintain professional accreditations.
• Identify potential quality of care issues and develop criteria/guidelines with data analysis.
• Maintain HIPAA confidentiality.
• Provide decisions with financial risk up to $500,000 for shield/cross claims.
• May participate in special projects and meetings.
• Follow URAC standards as required.

Skills

Analytical skills

Independent decision-making

Communication

Education

RN licensure

Bachelor’s degree in nursing preferred

Tools

InterQual

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.
• Mu t 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