Medical Review Nurse

🕒 August 13

⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 67%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Blue Cross and Blue Shield of Louisiana

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1934

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Blue Cross and Blue Shield of Louisiana is an independent licensee of the Blue Cross Blue Shield Association, offering a range of health insurance products and services in the state of Louisiana. The company provides health, dental, and travel insurance options, including Medicare Advantage plans such as HMO and PPO. They focus on delivering comprehensive healthcare coverage through various plans to meet varying customer needs, while partnering with doctors, hospitals, and clinics to ensure quality care and support. Additionally, the company emphasizes wellness programs, cost-saving opportunities, and accessibility for its members.

📋 Description

• Coordinate, process, and manage inpatient and outpatient claims from a medical standpoint • Apply contractual limitations, exclusions, medical necessity criteria, and medical judgment to claims and service requests • Maintain compliance with regulatory guidelines, URAC standards, MNRO, and DOL laws and regulations • Maintain contact with healthcare providers and subscribers to obtain medical information • Obtain review requests and notify determinations to BAD, ITS, NASCO, FEP, BMS, and legal • Prepare medical-information documentation and complete research • Make recommendations and refer potential denials to Medical Directors and Management • Complete correspondence to providers and subscribers regarding determinations and appeal processes or rights • Meet staff and unit performance expectations • Collaborate with team members and communicate improvement suggestions to the supervisor • Perform other job-related duties within the scope of responsibilities

🎯 Requirements

• High School Diploma or equivalent is required • 4 years of recent LPN experience providing direct patient care • 1 year of authorization, medical review, and case management experience • 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 • Current, unrestricted LPN license in the state of Louisiana and/or in the required jurisdictions, or where services are provided • CPUR, CPC, or CMCN certification preferred upon hire; required within 24 months in position • A comparable professional medical review or case management certification is preferred • Applicants must be authorized to work for Louisiana Blue in the United States without employer-sponsored immigration support • Must undergo background and pre-employment drug screening after an offer and prior to hire

🏖️ Benefits

• Resources to live well and be healthy • Continued learning and skill development • Professional growth opportunities • Opportunities to serve local communities • Reasonable accommodations for individuals with disabilities • Smoke- and tobacco-free workplace • Background and pre-employment drug screening • Drug Free Workplace