Medical Review Nurse

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: 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
• 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

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

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