3 Utilization Review RN Jobs in Baton Rouge, LA
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Franciscan Missionaries of Our Lady Health System
Baton Rouge, LA | Full Time
$48k-60k (estimate)
7 Days Ago
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Utilization Review RN
$73k-93k (estimate)
Contractor | Professional Associations
2 Weeks Ago
Blue Cross Blue Shield of Louisiana is Hiring an Utilization Review RN Near Baton Rouge, LA
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 PURPOSEResponsible 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. Responsible for identification of areas for improvement, and formulation of recommendations for solutions. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.
NATURE AND SCOPE
An Equal Opportunity EmployerAll BCBSLA EMPLOYEES please apply through Workday Careers.PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
Additional InformationPlease be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.
In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.JOB CATEGORY: Insurance
Residency in or relocation to Louisiana is preferred for all positions.
POSITION PURPOSEResponsible 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. Responsible for identification of areas for improvement, and formulation of recommendations for solutions. Accountable for complying with all laws, regulations and accreditation standards that are associated with duties and responsibilities.
NATURE AND SCOPE
- This role does not manage people
- This role reports to this job: Departmental Leadership
- Necessary Contacts: Healthcare providers, subscribers, BAD, ITS, NASCO, FEP, BMS, and Legal.
- Bachelor's in business administration, healthcare, computer science or related degree is required or
- In lieu of degree, RN license is required or
- In lieu of degree, LPN license to practice in Louisiana as well as 2 years of related experience is required or
- In lieu of degree, 4 years of related experience is required
- 3 years of direct patient care/clinical experience which includes two years of managed care is required
- Knowledge of standardized code sets and medical terminology is required
- Knowledge of provider and benefit contracts and the ability to interpret and apply the information is required
- Must demonstrate the ability to critically evaluate information making independent decisions and anticipating needs.
- Must demonstrate excellent interpersonal, administrative, and telephone skills.
- Working knowledge of MS Office and other relevant software is required
- Demonstrated ability to handle multiple tasks in customer friendly manner and provide expert support to peers while maintaining performance standards is required
- Nursing\RN - Registered Nurse - State Licensure And/Or Compact State Licensure Must be a Registered Nurse with a current Louisiana license.required
- Case Mgmt/Social Services\CPUR - Cert Prof Util Review Must be attained within first 24 months in position. required or
- Non Clinical\CPC and/or CCSP - Certified Professional Coder Must be attained within first 24 months in position. required
- Responsible for identifying areas of improvement, and identifying and vetting potential solutions with supervisor/manager and implementing solutions in a collaborative manner. May serve as a resource to others and train new staff with oversight of supervisor. May assist with gathering information for unit audits.
- 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.
- Responsible for meeting targets for staff and unit performance as required by company and management standards. Assists supervisor and other units of Care Management maintaining department timeliness standards and participating on cross-department projects.
- Interacts telephonically with patients and/or providers in order to determine patient care needs, compliance and effectiveness with planned interventions.
- Utilizes accepted review and LOS criteria in conjunction with appropriate professional nursing judgment to determine medical necessity, accurate length of stay, and discharge needs while maintaining compliance with federal and state regulations and standards. Monitors for, records, and appropriately addresses variances to optimal recovery care path.
- Utilizes appropriate professional nursing judgment in application of contractual benefits and limitations, administrative directives, and claims policy in order to direct the appropriate course of action throughout the continuum of care.
- Assesses and establishes a pertinent plan of care/clinical pathway to support optimal patient outcomes anticipating and preventing avoidable variation in utilization of services. Monitors case progression to ensure compliance with plan or need for re-evaluation and adjustment of plan.
- 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.
An Equal Opportunity EmployerAll BCBSLA EMPLOYEES please apply through Workday Careers.PLEASE USE A WEB BROWSER OTHER THAN INTERNET EXPLORER IF YOU ENCOUNTER ISSUES (CHROME, FIREFOX, SAFARI)
Additional InformationPlease be sure to monitor your email frequently for communications you may receive during the recruiting process. Due to the high volume of applications we receive, only those most qualified will be contacted. To monitor the status of your application, please visit the "My Applications" section in the Candidate Home section of your Workday account.
If you are an individual with a disability and require a reasonable accommodation to complete an application, please contact recruiting@bcbsla.com for assistance.
In support of our mission to improve the health and lives of Louisianians, Blue Cross encourages the good health of its employees and visitors. We want to ensure that our employees have a work environment that will optimize personal health and well-being. Due to the acknowledged hazards from exposure to environmental tobacco smoke, and in order to promote good health, our company properties are smoke and tobacco free.
Blue Cross and Blue Shield of Louisiana performs background and pre-employment drug screening after an offer has been extended and prior to hire for all positions. As part of this process records may be verified and information checked with agencies including but not limited to the Social Security Administration, criminal courts, federal, state, and county repositories of criminal records, Department of Motor Vehicles and credit bureaus. Pursuant with sec 1033 of the Violent Crime Control and Law Enforcement Act of 1994, individuals who have been convicted of a felony crime involving dishonesty or breach of trust are prohibited from working in the insurance industry unless they obtain written consent from their state insurance commissioner.Additionally, Blue Cross and Blue Shield of Louisiana is a Drug Free Workplace. A pre-employment drug screen will be required and any offer is contingent upon satisfactory drug testing results.JOB CATEGORY: Insurance
Job Summary
JOB TYPE
Contractor
INDUSTRY
Professional Associations
SALARY
$73k-93k (estimate)
POST DATE
05/26/2024
EXPIRATION DATE
06/23/2024
WEBSITE
bcbsla.com
HEADQUARTERS
BATON ROUGE, LA
SIZE
1,000 - 3,000
FOUNDED
1934
TYPE
Private
REVENUE
$1B - $3B
INDUSTRY
Professional Associations
Related Companies
About Blue Cross Blue Shield of Louisiana
BCBSLA is a managed health care company that provides health insurance coverage for individuals and families.
Show more
The job skills required for Utilization Review RN include Managed Care, Leadership, Patient Care, etc. Having related job skills and expertise will give you an advantage when applying to be an Utilization Review RN. That makes you unique and can impact how much salary you can get paid. Below are job openings related to skills required by Utilization Review RN. Select any job title you are interested in and start to search job requirements.
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The following is the career advancement route for Utilization Review RN positions, which can be used as a reference in future career path planning. As an Utilization Review RN, it can be promoted into senior positions as a Clinical Outcomes Manager that are expected to handle more key tasks, people in this role will get a higher salary paid than an ordinary Utilization Review RN. You can explore the career advancement for an Utilization Review RN below and select your interested title to get hiring information.
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