Louisiana Licensed Medical Review Nurse

Job Summary

Coordinating and managing in-patient and out-patient claims, the full-time Louisiana Licensed Medical Review Nurse will ensure compliance with regulatory guidelines and contractual limitations while working remotely.

Key responsibilities

• Reviews medical claims and applies medical judgment to determine benefits in accordance with contractual exclusions and medical necessity
• Prepares documentation and makes recommendations for potential denials, ensuring compliance with URAC standards and relevant laws
• Communicates determinations and appeal processes to providers and subscribers, maintaining adherence to regulatory standards

Required qualifications

• High School Diploma or equivalent required
• 4 years of recent LPN experience with 1 year in authorization, medical review, or case management required
• Current, unrestricted LPN license in Louisiana required
• Knowledge of standardized code sets and medical terminology required
• CPUR, CPC, or CMCN certification preferred within 24 months of hire