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