Florida Blue Medicare Pre-Service Medical Review Nurse RN

Job Description

What Is Your Impact?

This position serves as Florida Blue Medicare's clinical expert in working with providers, facilities, and subscribers in overseeing the wellbeing of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.

The Key Responsibilities

• Review and resolve complex processing issues and utilization management cases, ensuring accurate and timely Medical Review processing of designated Pre-Service healthcare services.
• Responsible for more complex review requests. Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests to determine benefit coverage and medical necessity per established criteria meeting compliance standards and timeframes.
• Process Pre-Service Medical Review requests received via phone following internal policies and procedures accurately, timely and with attention to detail.
• Research requests not clearly meeting established criteria.
• Conduct review of subscriber's medical information in order to ensure appropriate benefit administration.
• Abstract clinical case presented, review cases and potential denials with the Medical Directors.
• Coordinate and maintain complete written documentation on all prior authorizations requests.
• Provides world class telephone customer service to plan members and/or providers by answering benefit questions, researching, and resolving issues and inquiries and ensuring members and providers understand the Company’s products and services.
• Conduct training of new staff members and providers as needed.
• The essential functions listed represent the major duties of this role, additional duties may be assigned.
• Important Information***
  

The selected candidate for this position will be expected to work rotating holidays and weekends. They will also need to be comfortable answering calls during shifts as well as be on a rotating call schedule.

What Is Required

• 3+ years related work experience. Experience Details: Combined experience in utilization management, case management, home health, and clinical
• 1 year utilization management experience to include but is not limited to managed care experience including CMS Regulatory Guidelines and general medical coverage guidelines with the ability apply them in various scenarios.
• Knowledge of ICD-10 Codes
• Excellent written and verbal communication and organizational skills
• Ability to work independently and handle multiple tasks
• Strong problem solving and decision making skills
• Flexible and self-motivated
  
  

Required Licenses And Certifications

RN - Registered Nurse - State Licensure and/or Compact State Licensure Florida License, Unrestricted

What Is Preferred

• Basic PC knowledge
• Medicare Advantage experience
• Knowledge of InterQual
  
  

General Physical Demands

Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

What We Offer

As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life, and global travel health insurance
• Income protection benefits: life insurance, Short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan includes employer match
• Paid time off, volunteer time off, 10 holidays and 2 Well-being days
• Additional voluntary benefits available as well as a comprehensive wellness program
  
  

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

Salary Information

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Typical Annualized Hiring Range: $69,400 - $86,800

Annualized Salary Range:$69,400 - $112,800

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.

About Us

At GuideWell, we are committed to making diversity, equity and inclusion part of everything we do. We believe in hiring people who represent the communities we serve while creating a workplace that encourages a sense of belonging for everyone, no matter who you are or where you come from.

From students to former military to seasoned professionals, our family of mission-based companies are stronger because of the unique talents and skills of our employees. We believe everyone’s contribution has the power to help people and communities achieve better health. Find your new team today.

About The Team

Florida Blue, A GuideWell Company, has been providing health insurance to residents of Florida for 75 years. Driven by its mission of helping people and communicating to achieve better health, the company serves more than five million health care members across the state. We are looking for exceptional people who will bring our mission to life and succeed by putting the members first.