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Job Summary:
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.
 
Job Functions:
  • 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 weekend day assignment on a rotational bases if/as needed
     
    Minimum Job Requirements:
  • 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
  • Must be able to work Saturday or Sunday on weekly basis
  • 4/10 hr Option available
  •  
     
    Business Specific Criteria (Preferred Skills):
  • 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.

Driving
Incidental Driving
We are an Equal Opportunity Employer/Protected Veteran/Disabled.

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