Medical Review Nurse

Job description

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 Blue Cross. 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. 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 experience and c...