With the support of the department manager, carries primary responsibility for leading and management of key data systems critical to conducting precertification and case management (PCCM) activities and programs. This includes but is not limited to identifying, researching, trending, testing, coordinating, communicating, documenting, and implementing precertification, case management, discharge call outreach, and pharmacy internally developed electronic health record (EHR) data system, titled UM system, activities or projects that affect the operation of the department. Use of data and technology daily to monitor systems (ie. UM, FEP Direct, etc.) and apply clinical knowledge for recommendations for designing effective workflow for the activities conducted in the department. Analyze EHR data and reports from various sources from a clinical perspective for trending, identifying program or care initiatives, to include the analysis of data for mental health parity (MHP) and CMS programs. Make recommendations for changes based on data findings. Research, develop, and implement new technology. Train nursing staff to use technology, answer questions, and monitor results.

This position will be required to be onsite the first 6 months to complete the training period. This position is eligible to work 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.

• Make a Positive Impact: Your work will directly contribute to the health and well-being of Kansans.
• Family Comes First: Total rewards package that promotes the idea of family first for all employees.
• Dynamic Work Environment: Collaborate with a team of passionate and driven individuals.
• Trust: Work for one of the most trusted companies in Kansas
• Flexibility: options to work onsite, hybrid or remote available after training
• Inclusive Work Environment: We pride ourselves on fostering a diverse and inclusive workplace where everyone is valued and respected.

• Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The salary range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive salaries that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts.

• Works with precert, case management, and other internal or external staff for precertification, alternative care, case management, discharge call outreach, and resource utilization activities for coordination, management, and identification of UM system requirements necessary to develop and maintain department data systems.
• Works as a liaison in communicating to IS the UM system requirements (writes business requirements documents) to assure the coding of the new data system or enhancements to current data system will be done correctly and contributes to outlining priorities. Requires the use of Agile process.
• Responsible for testing all aspects of the UM system for project development and implementation. Participate on corporate teams and committees. Communicate information learned from these meetings to manager and staff.
• Uses nursing clinical knowledge along with system perspective in development of stratification criteria for identifying and prioritizing members for case management programs.
• Participate, facilitate, and lead the updates for system logic for changes of ICD, CPT, and HCPCS, InterQual periodic/annual review to include length of stay trending clinical analysis.
• Must be able to globally understand if EHR data requirements possible, sources of data being requested, and evaluate impacts to other systems. Identify clinical data required to be shared per regulating bodies with various entities.
• Serve as resource person to providers and staff on the UM system, InterQual, Blue Access for loading external precerts, Blue Squared for communicating single case agreements, and clinical messaging, and medical review issues. This also includes training of new and existing staff on the use of the UM system.
• Analyze and optimize system performance based on reports. Investigate problems with applications as they are identified, determine solutions, and evaluate the need to act. Collaborate with IT for a resolution to include requirements, testing, and communicating to staff.
• Responsible for performing all job functions within the scope of the Kansas Nurse Practice Act and follow URAC standards as required for essential job functions.
• Responsible for maintaining an awareness and understanding of the business unit recovery plan for the department and the corporation’s business continuity program in general. This includes disaster recovery system testing.

• Kansas Registered Nurse license
• Three to five years clinical RN experience.

• Bachelor of Science of Nursing (BSN).
• Acute medical/surgical.
• Bachelor’s degree and/or experience in computer science, nursing informatics, health information technology or healthcare informatics.
• Two years electronic health record data systems development/modifications and/or editing processes.
• Working knowledge of ICD, CPT, and HCPCS coding.

• Base compensation is only one component of your competitive Total Rewards package
  • Incentive pay program (EPIP)
  • Health/Vision/Dental insurance
  • 6 weeks paid parental leave for new mothers and fathers
  • Fertility/Adoption assistance
  • 2 weeks paid caregiver leave
  • 5% 401(k) plan matching
  • Tuition reimbursement
  • Health & fitness benefits, discounts and resources

May 1, 2024 Salary