Precert Nurse Consultant

Blue Cross and Blue Shield of Kansas•Topeka, KS

6d•Hybrid

About The Position

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.

Requirements

Associate's degree in Nursing (ADN) required
Minimum 3 years' experience in a clinical nursing role required
Current, active, unrestricted Kansas RN License required
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.

Nice To Haves

Bachelor's degree or equivalent in Nursing, Healthcare, or similar field preferred
Acute medical/surgical experience preferred
Previous experience in Precertification/Utilization Management (UM) preferred

Responsibilities

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).