Medical Review Claims - Nurse Consultant

This job was posted by https://www.kansasworks.com : For more information, please see: https://www.kansasworks.com/jobs/13280131

• *What youll 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.

• Must follow current URAC standards as required for essential job

functions.

• *What you need**

###

Knowledge/Skills/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 team 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. ###

Education and Experience

• Current unrestricted Kansas RN licensure required. Baccalaureate in nursing preferred.

• Minimum 3-5 years of clinical nursing experience - required.
• RN experience in Surgical, Medical, Obstetric, and/or Utilization

Management preferred.

• CPC certified or obtain certification by American Academy of

Professional Coders within three years of hire. ###

Physical Requirements

• 90-100% sedentary work setting using a computer

• *Benefits & Perks**

• Base pay 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
• 5% 401(k) plan matching
• Tuition reimbursement
• Health & fitness benefits, discounts and resources

Apply Job! Apply to this Job