Clinical Review Nurse

Guided by our core values and commitment to your success, we provide health, financial and lifestyle benefits to ensure a best-in-class employee experience. Some of our offerings include: Highly competitive total rewards package, including comprehensive medical, dental and vision benefits as well as a 401(k) plan that both the employee and employer contribute Annual incentive bonus plan based on company achievement of goals Time away from work including paid holidays, paid time off and volunteer time off Professional development courses, mentorship opportunities, and tuition reimbursement program Paid parental leave and adoption leave with adoption financial assistance Employee discount program

Job Description

Summary: Utilizes a collaborative review process of benefits, minimally necessary clinical information and evidence-based clinical guidelines to formulate decisions regarding medical necessity, pre-existing conditions, benefits and/or individual consideration reimbursement allowables using varied and broad clinical expertise. Acts as a member and provider advocate promoting and coordinating delivery of quality, cost-effective healthcare services based on medical necessity and contractual benefits. The candidate for this position must reside in the Kansas City metropolitan area.

Job Description

Conducts pre-service, concurrent and / or post-service utilization management reviews to ensure appropriate use of the health care system and to maximize health care dollars. Schedules time effectively; works with minimal supervision; handles multiple projects simultaneously; prioritizes work appropriately to streamline process and identifies opportunities for quality or process improvement; Uses critical thinking skills, problem solving and organizational skills; works as a team member while maintaining a positive attitude Ensures that reviews and determinations meet requirements with applicable URAC and NCQA guidelines as well as federal and state mandates; Maintains confidentiality of all PHI in compliance with state and federal laws; Reads, understands and follows medical policy and all corporate, divisional and departmental policies and procedures. Reviews provider and/or member submitted medical information to determine pre-existing, medical necessity, benefits & eligibility, and/or reimbursement of a requested service, product or procedure utilizing professional knowledge, medical literature, medical records, certificate guidelines, medical policy, approved clinical guidelines, and several complex and varied computer application software systems. Refers cases that do not meet criteria to the Medical Director with an appropriate clinical analysis, summaries and recommendations. Contributes in the discharge planning of members to appropriate acute, SNF, in-patient hospice or rehab facilities or discharge to home with a safe plan Recognizes, documents and reports inappropriate billing patterns or utilization trends of professional and institutional providers to the appropriate business owner. Communicates effectively with team members, other departments within the organization, management, members &/or providers; assess and educate members &/or providers on a proactive basis; utilizes internal, community and other healthcare resources as well as clinical knowledge to maximize outcomes, as well as referrals to case management, disease management, community health specialist, etc. Contributes to reaching or exceeding departmental, divisional and corporate goals; knowledgeable of business goals, progress toward accomplishment of goals and works collaboratively with peers to meet or exceed annual departmental targets; analyzes qualitative and quantitative data in developing strategies to improve provider performance and member satisfaction.

Minimum Qualifications

Associate degree in nursing 3+ years full-time direct patient care clinical experience in medical/surgical, pediatrics, and/or obstetrics. Proven experience effectively presenting information and responding to questions from groups of managers, clients, customers, and the general public. Proven experience in problem definition, data collection to establish facts, and drawing valid conclusions to solve practical problems while working with a variety of concrete variables in situations where only limited standardization and direction exists. RN license in Missouri and Kansas

Preferred Qualifications

Bachelor’s degree in nursing preferred. 1+ year(s) of utilization review, disease management, and/or case management experience. Knowledge of ICD, CPT and HCPCS coding. Knowledge of URAC and NCQA guidelines and state and federal regulations Intermediate keyboarding skills. Intermediate knowledge of FACETS. Intermediate knowledge of Clinical Guidelines. Blue Cross and Blue Shield of Kansas City is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, among other things, race, color, religion, sex, sexual orientation, gender identity, national origin, age, status as a protected veteran, or disability. At Blue Cross and Blue Shield of Kansas City (Blue KC), we have long put our members first by developing products and services to meet their needs. From our founding in 1938 to more than 80 years of experience in innovative, patient-centered healthcare coverage, Blue KC continues to keep our members at the center of everything we do. As a market leader, we continue to embrace new ideas to make healthcare more affordable and to improve the customer experience. Come join us! Blue Cross and Blue Shield of Kansas City will extend reasonable accommodations to qualified individuals with disabilities who are otherwise not able to fully utilize electronic and online job application systems. For assistance, please send an email to Recruitingteam@bluekc.com. EOE/Veterans/Disability Affirmative Action Employer E-Verify Participation Equal Employment Opportunity/Nondiscrimination/Affirmative Action Policies IER Right to Work FMLA Employee Polygraph Protection Act