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