Medical Review Claims - Nurse Consultant - #1409546

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