Medical Review Nurse

Requirements

• Education High School Diploma or equivalent is required
• Work Experience 4 years of recent LPN experience providing direct patient care with one year of authorization, medical review, and case management experience is required
• Skills and Abilities 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
• Knowledge of health insurance contracts/benefits is preferred
• Licenses and Certifications Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided required
• CPUR, CPC, or CMCN certification is preferred upon hire; required within 24 months in position.
• A comparable professional medical review or case management certification is preferred
• 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.
• Additional Accountabilities and Essential Functions
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.
• An Equal Opportunity Employer
• All internal employees please apply through Workday Careers.
• PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
• Additional Information
• If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.
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Benefits

Additional Information

We take great strides to ensure our employees have the resources to live well, be healthy, continue learning, develop skills, grow professionally and serve our local communities. We invite you to apply for a career with us. Residency in or relocation to Louisiana is preferred for all positions. POSITION PURPOSE 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. NATURE AND SCOPE This role does not manage people This job reports to: Departmental Leadership Necessary Contacts: In order to effectively fulfill this position, the incumbent must be in contcact with: Healthcare providers and subscribers to obtain medical information. Obtains request for reviews from and notifies determinations to BAD, ITS, NASCO, FEP, BMS, and legal.

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