Nurse Consultant - Remote Claims & Policy Expert

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

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.