Medical Review Nurse

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

2d

About The Position

The Medical Review Nurse coordinates, processes, and manages inpatient and outpatient claims from a medical standpoint, ensuring proper administration of contractual limitations and exclusions, including medical necessity, and compliance with regulatory guidelines. The role reviews medical claims and service requests, applies medical judgment and/or criteria to determine benefits for pre-service and post-service matters, documents medical information and research, and refers potential denials to Medical Directors and Management when necessary. It also prepares compliant correspondence to providers and subscribers about determinations and appeal rights, and works with healthcare providers, subscribers, and internal departments to obtain and communicate review information. This position does not manage people and reports to Departmental Leadership.

Requirements

• High school diploma or equivalent.
• Four years of recent LPN experience providing direct patient care, including one year of authorization, medical review, and case management experience.
• Current, unrestricted LPN license in Louisiana and/or in the required jurisdictions, or where services are provided.
• Knowledge of standardized code sets and medical terminology.
• Proficiency in the use of standardized code sets.
• Excellent interpersonal, administrative, and telephone skills.
• Working knowledge of MS Office.
• Ability to handle multiple tasks in a customer-friendly manner while maintaining performance standards.

Nice To Haves

• Knowledge of health insurance contracts and benefits.
• CPUR, CPC, or CMCN certification upon hire; certification is required within 24 months in the position.
• A comparable professional medical review or case management certification.
• Residency in or relocation to Louisiana is preferred.

Responsibilities

• Review medical claims and requests for services, applying medical judgment and/or criteria to determine pre-service and post-service benefits according to contractual benefits, limitations, and exclusions.
• Prepare documentation of medical information, conduct research, make recommendations, and refer potential denials to Medical Directors and Management when necessary.
• Complete correspondence to providers and subscribers about determinations and appeal processes and rights in accordance with regulatory standards.
• Meet targeted expectations for staff and unit performance as required by BCBSLA and department management.
• Collaborate with team members and communicate suggestions for improvement to the supervisor to support the corporate diversity initiative.
• Obtain medical information from healthcare providers and subscribers, and obtain review requests from and notify determinations to BAD, ITS, NASCO, FEP, BMS, and legal.
• Perform other job-related duties as assigned within the scope of responsibilities.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED