Nurse Consultant

With the support of the department manager, carries primary and independent responsibility for the day-to-day operations of reviewing, processing, and communicating with providers, The Kansas Insurance Department (via CSC) and internal staff involved in making independent medical decisions regarding predeterminations, claims, and appeals along with other inquiries in accordance with medical policy, standards of medical practice, and within contractual benefits. These decisions affect members and providers. 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, medical necessity, cost effectiveness, and predeterminations. This position also carries primary responsibility for assuring proper claims payment decisions, researching and developing new code updates, communicating with transplant hospital coordinators, researching requests for new medical treatments, pulling and analyzing reports. Responsible for performing all activities within state, HIPAA, DOL, InterQual, and MTM gorals or guidelines.

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Essential Functions

• Responsible for independent timely resolution of predeterminations, claims, reports, coding changes, internal requests, inquiries to determine medical necessity, correct coding, allowances based on medical policy/InterQual criteria and/or physician consultant recommendations, responses to audit/CSC requests and coding assistance requests throughout the company.
• Must have comprehensive knowledge for review of a wide range of services to include, but not limited to, ambulance, dental, laboratory, radiology, anesthesia, drug, durable medical equipment, surgical services, evaluation & management, therapies, inpatient, outpatient, home health, hospice, ambulatory surgery center, psychiatric, and transplants.
• Ability to apply clinical criteria, guidelines, and medical policy to ensure appropriate determination of benefits and services in accordance with the member's specific benefit plan. This requires interpretation of member benefit language for multiple types of member contracts.
• Assume a leadership role in determining the direction of claims, predeterminations, coding changes and contract interpretations. This diverse activity requires the nurse consultant to facilitate the development of processes that will enhance proficiency to increase member/provider satisfaction while ensuring proper use of member dollars.
• The nurse consultant must determine cost effectiveness of all claims and research/review claims/predeterminations/appeals/pre-certifications to compare ongoing services and approval or denials.
• Nurse consultant must respond to inquiries from providers, members, internal personnel, and group representatives concerning medical decisions. Monitors ongoing services and makes independent recommendations to appropriate internal staff and makes suggestions as appropriate.
• Serve as resource person to providers and staff regarding member benefits and medical review issues. Coordinates activity for appropriate claims payment including updates to the claims operation manual.
• Responsible for providing quality nurse consultant services in a manner compliant with department quality indicators.
• Obtains, records, and coordinates all nurse consultant inquiries and relays information to departments including Medical Director, BCBSKS Customer Service Representatives, claims staff, marketing, fraud, case management, precertification, medical practice analysis, pharmacy, institutional and professional relations, behavioral health vendor, and legal counsel when necessary.
• Has freedom to obtain and conduct review of medical information without direct supervision. Must determine through independent medical knowledge which cases require medical consultant expertise. All such determinations must be made under limited and extreme time restraints. Assists in reviewing medical records information regarding technologies and procedures.
• Responsible for reviewing and/or coordinating unusual or complex claims until resolved to include preparing and presenting case scenarios to the corporate medical director with appropriate medical, financial or cost/benefit information for review and input.
• 90% of daily activity requires the use of PC and/or telephone.
• 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 providing clinical support for MR analysts and other internal staff as needed. Responsible for appropriate risk management activities.
• Must follow current URAC standards as required for essential job functions.

Qualifications

Education:

Baccalaureate in nursing preferred. Current unrestricted Kansas RN licensure required. Current American Academy of Professional Coders credentials as a Certified Professional Coder (CPC) or ability to obtain certification within three years of employment.

Experience:

Minimum of three to five years Registered Nurse experience with two years of acute medical or surgical RN clinical experience. PREFERRED: Experience utilizing/analyzing CPT/AMA Coding.

Skills:

• The Nurse Consultant must be knowledgeable about the reimbursement structures, contract requirements, and coding requirements in multiple areas of health care.
• Must be knowledgeable of current HIPAA, KDOL, and AMA/CPT requirements and perform job functions to meet these requirements.
• 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 self-direct, self-motivate, make independent decisions, and prioritize daily activity.
• Ability to handle sensitive situations in a positive, professional manner.
• Possess high degree of honesty, loyalty, and integrity.
• Must be comfortable discussing reimbursement with internal staff and transplant provider coordinators.
• Ability to clinically research/analyze reports and recommend, create, and implement processes or medical policy changes.
• Must be able to work collaboratively in a teaming environment.
• Schedule could require alternative work hours, which may include evenings and/or weekends.
• Awareness and understanding of current provider medical and utilization practices.
• Capable of using a telephone, calculator, and personal computer 90% of the day.
• Capable of complying with all Kansas laws and regulations regarding the operation and the use of a motor vehicle.
• Must have a valid driver's license.
• Able to travel including overnight.

Compensation

Min $60,748

Mid $75,935

Posting Close Date

September 24, 2021

Pay Rate Type

Salary