Medical Review Nurse

This is a fully remote position, open to applicants in Louisiana.

📋 Description

• Oversee, process, and manage both inpatient and outpatient claims from a medical perspective.

• Utilize medical judgment and criteria to assess benefits for both pre-service and post-service requests.

• Evaluate contractual exclusions, cosmetic procedures, medical necessity, and administrative discrepancies.

• Compile medical-information documentation and conduct necessary research.

• Provide recommendations and escalate potential denials to Medical Directors and Management.

• Draft correspondence to providers and subscribers concerning determinations and the appeal processes/rights.

• Achieve targeted goals for both staff and unit performance.

• Work collaboratively with team members and share improvement suggestions with the supervisor.

• Execute other job-related tasks within the scope of responsibilities.

⛳️ Requirements

• A High School Diploma or equivalent is mandatory.

• A minimum of 4 years of recent LPN experience in direct patient care is required.

• At least one year of experience in authorization, medical review, and case management.

• Familiarity with standardized code sets and medical terminology is essential.

• Proficiency in using standardized code sets is necessary.

• Outstanding interpersonal, administrative, and telephone communication skills are required.

• A working knowledge of MS Office is expected.

• Capability to manage multiple tasks in a customer-friendly way while upholding performance standards.

• A current, unrestricted LPN license in Louisiana and/or applicable jurisdictions is required, or in areas where services are provided.

• CPUR, CPC, or CMCN certification must be obtained within 24 months of assuming the position.

• Successful completion of background checks and pre-employment drug screenings is mandatory prior to hiring.

🏝️ Benefits

• Access to resources for wellness, health, ongoing learning, skill development, professional growth, and community service.

• Reasonable accommodations available for individuals with disabilities.

• Company properties are smoke and tobacco-free.

• A drug-free workplace policy is enforced.