Precert 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

6 weeks paid parental leave

Fertility/Adoption assistance

2 weeks caregiver leave

401(k) plan matching up to 5%

Tuition reimbursement

Health & fitness benefits

Job summary

Blue Cross and Blue Shield of Kansas is seeking a precertification nurse consultant to manage day-to-day review and processing of inpatient and outpatient precertification, prior authorizations, and alternative care requests. You will work with members and providers to ensure timely, accurate decisions.

Requirements include ADN, and a preferred BSN; at least 3 years in clinical nursing with UM/precertification experience.

Qualifications

• Associate's degree in Nursing (ADN) required.
• Bachelor's degree or equivalent in Nursing, Healthcare, or similar field preferred.
• Minimum 3 years' experience in a clinical nursing role.
• Experience in Precertification/Utilization Management preferred.

Responsibilities

• Research, review, process, and communicate precertification for inpatient/outpatient services.
• Perform prior authorizations and coordinate care requests.
• Review medical necessity and contract eligibility independently.
• Coordinate with medical consultants and apply InterQual criteria.
• Travel: minimal travel 0-10%.

Skills

InterQual criteria knowledge

Communication skills

Independent decision making

PC & calculator use

Education

Associate's degree in Nursing (ADN)

Bachelor's degree in Nursing or related field

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

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 Minimal 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

Schedule could require alternative work hours, which may include evenings and weekends

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.