Precert Nurse Consultant

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. Orientation of precertification activities to new employees within the department (Precert, Case Management, Medicare Advantage, etc).

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 compensa