Medical Review Nurse

Blue Cross and Blue Shield of Louisiana•Remote-LA, LA

2d•Onsite

About The Position

Responsible for coordinating, processing and managing all in-patient and out-patient claims from a medical standpoint to ensure proper administration of contractual limitations and exclusions to include medical necessity, while maintaining compliance with regulatory guidelines. This role does not manage people and reports to Departmental Leadership. Necessary contacts include healthcare providers and subscribers to obtain medical information, and obtaining requests for reviews from and notifying determinations to BAD, ITS, NASCO, FEP, BMS, and legal.

Requirements

High School Diploma or equivalent is required
4 years of recent LPN experience providing direct patient care with one year of authorization, medical review experience and case management is required
Knowledge of standardized code sets and medical terminology is required
Proficiency in the use of standardized code sets is required
Must demonstrate excellent interpersonal, administrative, and telephone skills.
Working knowledge of MS Office is required
Demonstrated ability to handle multiple tasks in customer friendly manner while maintaining performance standards is required
Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided required

Nice To Haves

Knowledge of health insurance contracts/benefits is preferred
CPUR or CPC certification is preferred upon hire; required within 24 months in position.
A comparable professional medical review or case management certification is preferred

Responsibilities

Reviews medical claims and requests for services and applies medical judgment and/or criteria in determining the benefits for pre-services and post-services according to contractual benefits and limitations, (i.e., contractual exclusions, cosmetic procedures, medical necessity, and administrative discrepancies) to ensure the proper administration of contractual and medical limitations/exclusions.
Prepares documentation of medical information, completes research, makes recommendations, and refers potential denials to the Medical Directors and Management, when necessary, to ensure compliance with URAC standards, MNRO and DOL laws and regulations.
Completes correspondence correctly when necessary to providers and subscribers to ensure that customers are aware of the determinations and appeal processes/rights meeting all regulatory standards.
Meets targeted expectations for staff and unit performances as required by BCBSLA and department management.
Collaborates with team members and communicates to the supervisor suggestions for improvement to ensure adherence to the corporate initiative of diversity.
Perform other job-related duties as assigned, within your scope of responsibilities.