Medical Review Nurse RN

Job Description

What Is My Impact?

The Medical Review Nurse reviews, authorizes, coordinates, and responds to requests for services for Florida Blue members. This position also communicates telephonically with providers and their offices, and occasionally with members. Makes decisions based on established policies and procedures, Florida Blue medical coverage guidelines, benefits, InterQual criteria, nursing knowledge. The nurse also refers cases to Florida Blue medical directors for benefit determination.

Key Responsibilities

• Apply clinical knowledge and expertise to review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests per established criteria, while meeting compliance standards and timeframes
• Review all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity
• Review cases and potential denials with the Medical Directors
• Research requests not clearly meeting established criteria
• Assist the Prior Authorization non-clinical representatives with the Prior Authorization process
• Coordinate and maintain complete written documentation on all prior authorizations’ requests.
• Collaborate with other Florida Blue departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors.
• Log into phone queue to service providers as appropriate
• Answer inbound calls regarding authorizations within established time frame
• Document contact information in electronic medical record system
• Maintain productivity
• Handle calls professionally
• Provide accurate prior authorization information to provider offices
• Perform other duties as assigned
• Available to work “on call” weekends day and evenings assignment on a rotational basis
• May require 9:30 a.m. to 6:00 p.m. shift coverage
  
  

What Is Required

• Active, current, valid, unrestricted Florida State Registered Nurse (RN)
• At least two (2) years clinical experience
• Previous Medicare or Managed Care experience, including medical review, prior authorization, or appeals, with experience utilizing established criteria to make medical review determination
• Experience working with one or more of the following coding systems: ICD-10, CPT-4 and HCPC
• Excellent written and verbal communication skills
• Experience working with multiple research/processing systems
• Experience working with MS Word, Excel, and PowerPoint
• Ability to work on call as needed
  
  

What Is Preferred

• Bachelor of Science in Nursing (BSN) degree
• Experience with utilization management systems or clinical decision-making tools such as: Medical Coverage Guidelines (MCG), CMS guidelines, and/or InterQual
• Experience working with Florida Blue systems such as: JIVA, Diamond, Quest, Convergence, and/or Siebel
• Call center experience
  
  

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 contribution and employer match
• Paid time off, volunteer time off, and 11 holidays
• Additional voluntary benefits available and 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: $68,100 - $85,100

Annualized Salary Range: $68,100 - $110,600

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're passionate about building a workplace culture where everyone feels valued and empowered to succeed. We're committed to creating an environment that values and respects the unique perspectives and experiences of all our employees. Our mission is to help people and communities achieve better health, and we believe that everyone's contribution has the power to make a difference. Join our team and help us achieve our mission of helping people and communities achieve better health.

About The Team

At Florida Blue, we're driven by a singular mission: to help people and communities achieve better health. As a leading health solutions company, we're dedicated to making a meaningful difference in the lives of our members, customers, and the communities we serve. With a legacy of innovation and a commitment to excellence, we're shaping the future of healthcare in Florida and beyond.