This job was posted by https://www.kansasworks.com : For moreinformation, please see: https://www.kansasworks.com/jobs/12815851 Makea difference in people\'s lives by ensuring access to healthcare throughaccurate and timely medical claims review at Blue Cross Blue Shield.Leverage your medical knowledge and analytical skills to investigatecomplex claims, identify opportunities for provider education, andcontribute to our mission of providing fast and fair access tohealthcare.

　　** This position is eligible to work onsite or remote in accordancewith our Telecommuting Policy. Applicants must reside in Kansas orMissouri or be willing to relocate as a condition of employment.

　　Why Join Us

　　Make a Positive Impact: Your work will directly contribute to the healthand well-being of Kansans.

　　Family Comes First: Total rewards package that promotes the idea offamily first for all employees.

　　Professional Growth Opportunities: Advance your career with ongoingtraining and development programs.

　　Dynamic Work Environment: Collaborate with a team of passionate anddriven individuals.

　　Balance: paid vacation and sick leave with paid maternity and paternityavailable immediately upon hire. Work from home opportunities available.

　　What youll do

　　Responsible for independent review of medical records for informationnecessary to complete a timely and accurate review of provider claimsand CSC packages.

　　Responsible for knowing when contractual benefits may impact claimsreview and payment.

　　Responsible for accessing the appropriate medical necessity guidelinesor policy for review of requested services.

　　Responsible for identifying when a claim should be elevated to a higherlevel of review, i.e., nurse consultant, management, consultants.

　　Responsible for researching history, identifying appropriate guidelines,and formatting clear concise question(s) for claims needing nurse,management, or outside consultant review.

　　Responsible for identification and research of coding and billing issueswith appropriate written referral to Professional Relations for providereducation.

　　Responsible for providing support to internal staff (i.e., Marketing,Hotline, CSC), regarding questions about coding issues, medicalnecessity, and medical policy.

　　Responsible for initial research and preparation of information for allmedical necessity appeals.

　　Responsible for maintaining current knowledge regarding medicalnecessity guidelines as well as learning new policies and guidelines asthey are established.

　　Responsible for identifying areas of potential savings by referringlarge dollar cases to case management for possible intervention andreferral of high dollar drug claims to nurse consultants.

　　Responsible for identifying areas of aberrant utilization for providereducation, guideline, and system changes.

　　Accesses claims/medical guidelines and policy, reimbursement schedules,and other information systems via computer ninety percent (90%) of theday.

　　Responsible for documenting predetermination requests and other outsidetelephone activity directly into the online tracking system (OTIS).