Medical Review Nurse

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. 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 contact 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. QUALIFICATIONS 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. ACCOUNTABILITIES AND ESSENTIAL FUNCTIONS 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. Additional Accountabilities and Essential Functions: The Physical Demands described here are representative of those that must be met by an employee to successfully perform the Accountabilities and Essential Functions of the job. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential functions. Perform other job-related duties as assigned, within your scope of responsibilities. 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. Equal Opportunity Employer An Equal Opportunity Employer Additional Information PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI). In support of our mission to improve the health and lives of Louisianians, we encourage the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free. We perform background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner. Additionally, we are a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results. Company Mission To improve the health and lives of Louisianians. Company Vision A better state of health through preventative, easier and more affordable healthcare. Blue Cross and Blue Shield of Louisiana Blue Cross and Blue Shield of Louisiana (Louisiana Blue) is incorporated as Louisiana Health Service & Indemnity company and is an independent licensee of the Blue Cross Blue Shield Association. Blue Cross and Blue Shield of Louisiana is licensed to sell products only in the state of Louisiana. #J-18808-Ljbffr