Medical Review Nurse

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⚜️ Louisiana – Remote

⚜️ Louisiana – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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 medical judgment and criteria to determine benefits for pre-service and post-service requests • Assess contractual exclusions, cosmetic procedures, medical necessity, and administrative discrepancies • 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/rights • Meet targeted expectations for staff and unit performance • 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 • One year of authorization, medical review, and case management experience • Knowledge of standardized code sets and medical terminology • Proficiency in 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 Louisiana and/or required jurisdictions, or where services are provided • CPUR, CPC, or CMCN certification required within 24 months in position • Successful completion of background and pre-employment drug screening required before hire

🏖️ Benefits

• Resources to live well, be healthy, continue learning, develop skills, grow professionally and serve local communities • Reasonable accommodations for individuals with disabilities • Smoke and tobacco-free company properties • Drug-free workplace