Remote Medical Review Nurse RN

Florida Blue

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Full-Time 32359

Get To Know US!
GuideWell and its family of forward-thinking companies are focused on helping people and communities achieve better health and are at the forefront in the transformation of health care.
As a highly integrated care team we empower members to optimize their health and achieve their health care goals by providing access to quality and affordable health solutions.

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 communities 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 member first.

Important information to know:

  • Available to work “on call” weekends day and evenings assignment on a rotational basis
    • On-call rotational assignment for after-hours and weekends.
    • May require 9:30 a.m. to 6:00 p.m. shift coverage

What is your impact?
The Medical Review Nurse reviews, authorizes, coordinates, and responds to requests for services for Florida Blue members. They will communicate 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.

What are your 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

What is required?
• Active, current, valid, unrestricted Florida State Registered Nurse (RN) / compact RN License that includes Florida
• 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
• Excellent written and verbal communication skills
• Experience working with multiple research/processing systems
• Experience working with MS Word, Excel, and PowerPoint

What is preferred?
• Bachelor of Science in Nursing (BSN) degree
• Experience working with one or more of the following coding systems: ICD-10, CPT-4 and HCPC
• 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.
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: $64,800 – $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.