Louisiana Licensed Medical Review Nurse

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