Nurse Consultant

Blue Cross & Blue Shield of Kansas, Inc.; Topeka (KS); Hybrid; USD 74,000 - 92,000; Full time

Benefits offered by this job

Health insurance

Vision insurance

Dental insurance

Parental leave

Fertility/Adoption assistance

Caregiver leave

401(k) match

Tuition reimbursement

Wellness programs

Job summary

Blue Cross and Blue Shield of Kansas seeks a Nurse Consultant to manage predeterminations, claims, and appeals, applying medical policy and InterQual criteria while communicating decisions to staff, providers, members, and the Kansas Insurance Department. This role emphasizes clinical leadership, policy adherence, and accessibility across remote, hybrid, or onsite settings.

The position requires RN licensure in Kansas and a nursing degree, plus CPC certification within three years.

Qualifications

• Current unrestricted Kansas RN licensure required.
• Bachelor's degree in nursing preferred.
• CPC certification within three years of hire.

Responsibilities

• Independently resolve predeterminations, claims and appeals using medical policy and InterQual criteria.
• Respond to inquiries on medical necessity, coding, allowances, CSC audits, and coding assistance.
• Provide clinical support for MR analysts and internal staff.
• Operate within the Kansas Nurse Practice Act and maintain professional accreditations.
• Identify quality of care issues and make appropriate referrals.
• Gather QA/Utilization data and develop criteria and guidelines.
• Maintain HIPAA confidentiality and professional standards.
• Make decisions that may set precedent with financial risk up to $500,000.
• Lead special projects and meetings as needed.
• Follow URAC standards for essential job functions.

Skills

Clinical nursing

Analytical skills

Communication skills

Education

RN licensure in Kansas

Bachelor's degree in nursing

CPC certification within 3 years

Tools

InterQual criteria

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. For more than 70 years, Blue Cross and Blue Shield of Kansas has built a reputation of trust. As we move forward in this new era of health care we want to continue that tradition. Whether a member needs Blue Cross to cover an annual check-up or give them peace of mind during a major medical crisis, we want our members to know they can trust BCBSKS to meet their needs. Our mission: Being the insurer Kansans trust with their health.

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. For more than 70 years, Blue Cross and Blue Shield of Kansas has built a reputation of trust. As we move forward in this new era of health care we want to continue that tradition. Whether a member needs Blue Cross to cover an annual check-up or give them peace of mind during a major medical crisis, we want our members to know they can trust BCBSKS to meet their needs. Our mission: Being the insurer Kansans trust with their health.