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