Remote FBM Pre-Serv Med Rev Nurse RN

Florida Blue

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United States Clinical Full-Time 31553

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

Essential Functions

  • The essential functions listed represent the major duties of this role, additional duties may be assigned.
  • 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.

Qualifications

Required Work Experience
3+ years related work experience. Experience Details: Combined experience in utilization management, case management, home health and clinical

Required Management Experience
No supervisory/management experience required

Required Licenses and Certifications
RN – Registered Nurse – State Licensure And/Or Compact State Licensure Florida license, Unrestricted

Additional Required Qualifications

1 year utilization management experience
ICD-9 Coding
Excellent planning, organizational skills
Excellent verbal and written communication skills
Self starter
Ability to work independently
Conflict resolution
Detail oriented
Ability to handle multiple tasks
Decision making skills
Flexibility

Additional Preferred Qualifications
Basic PC knowledge Managed care experience, Including InterQual Understanding of Regulatory Agencies Medicare Advantage 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.

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.

Annualized Salary Range: $66,400 – $107,900

Typical Annualized Hiring Range: $66,400 – $83,000

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.