This position is responsible for the day-to-day operations of reviewing and processing predeterminations, claims, appeals, and other inquiries utilizing independent decision making in accordance with medical policy, standards of medical practice, and within contractual benefits. Must be able to communicate these decisions to internal staff and to providers, members, and the Kansas Insurance Department (via CSC) as needed. The Nurse Consultant will serve as a primary resource for internal staff throughout the company regarding medical policy, correct coding, medical necessity, and other processes that relate to claims adjudication, cost effectiveness, and predeterminations. Responsible for performing all activities within state, HIPAA, DOL, InterQual, and MTM goals or guidelines.
"This position is eligible to work remote, hybrid or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment."
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