Medical Review Claims - Nurse Coordinator

Blue Cross and Blue Shield of Kansas•Topeka, KS

3d•$85,600 - $107,000•Hybrid

About The Position

The Medical Review Claims Nurse Coordinator directly oversees the day-to-day activities of a team of medical review nurse consultants. Co-responsible, with the other Coordinator and Analyst Supervisor, to research, develop, and implement all training / education materials for the entire Medical Review department. Responsible for ensuring employee production and quality meets department / company goals. Responsible for receiving, researching, answering all direct questions from employees and other departments / divisions regarding employee reviews / decisions. Lead multiple departmental meetings and projects. Participate in divisional meetings along with the Manager.

Requirements

Bachelor's degree or equivalent in nursing or health related field required
Minimum 6 years' experience in a clinical nursing role (Medical Review Claims experience counts) required
Current, active, unrestricted Kansas RN License required
Must be able to effectively supervise a team with diverse personalities, educational backgrounds, and various management and non-management levels with a wide range of technical / medical understanding.
Must be self-directed with the ability to make independent decisions and prioritize personal and employee production activities.
Must be able to review and manage sensitive situations related to employees and BCBSKS customers in a positive professional manner.
Maintain a working knowledge of medical trends that may affect department production.
Must have strong computer skills to operate effectively with company systems and programs.
Must be able to maintain a productive and professional relationship with multiple cross departmental and divisional teams.
Must be able to communicate technical / medical subjects to employees with sufficient clarity to explain decision outcomes and justify recommendations to team members, senior management, other departments / divisions.
Must have a strong analytical background.

Nice To Haves

Minimum 3 years' experience Medical Review Claims experience preferred
Minimum 1 years' experience in a supervisor or leadership role preferred
Certified Coder-AHIMA or AAPC within 3 years of hire required

Responsibilities

Accountable for performance monitoring, policy enforcement, termination process, disciplinary action, hiring, compliance and team development.
Maintaining accurate records of all hiring, firing and disciplinary actions.
Ensure supervised employees are compliant with all company, state, and federal regulations.
Lead / participate in multiple cross division/department teams.
Ensure all supervised employees maintain their clinical licensing and professional coder certifications.
Co-responsible for researching, creating, implementing, and maintaining all department processes and education / training material with regular team training sessions.
Accountable for identifying and researching production inconsistencies involving policy questions and other problem areas and present solutions to management.
Subject matter expert for department, division, and senior management inquiries.
Conduct regular audits and assessments of the claim review process to ensure accuracy, regulatory compliance, and identify areas for process improvement.
Provide ongoing support and mentorship to staff, fostering professional development and growth.
Accountable for independent approval of claims up to $1 million.
Must follow URAC standards as required for essential job functions.