Remote PreService Medical Review Nurse RN, FL

Florida Blue

Apply Now

Unlock Proven Email Templates to Land Your Dream Job!

 

Join successful job seekers – Complete a 3-minute LinkedIn survey now and get your templates instantly!

 

👉  Send Me the Templates Now!

United States Clinical Full-Time 31935

What is the impact?
The Pre-Service Medical Review Nurse will be working in a Call-Center environment and will be working on the phones in combination of written correspondences up to 8 or greater hours a day.  They will coordinate the resolution of claims requiring medical review either on a phone queue or written correspondences by working directly with providers and BCBSF internal resources by researching clinical information and medical criteria to resolve and document medical clearances and issues requiring medical decision making.   Additionally, they will complete authorization of selected services and procedures meeting internal and external regulatory requirements, educate providers regarding BCBSF’s electronic capabilities and utilization management process and will provide coaching and education to the team regarding Corporate Medical Clearance.

Important:  the required shift will be  9:30am  to 6:00pm

What are your key responsibilities?
•    Coordinate the resolution of claims requiring medical review either on a phone queue or written correspondences by working directly with providers and BCBSF internal resources by researching clinical information and medical criteria to resolve and document medical clearances/ issues requiring medical decision making
•    Complete authorization of selected services and procedures meeting internal and external regulatory requirements
•    Educate providers regarding BCBSF’s electronic capabilities and utilization management process
•    Provide coaching and education to the team regarding Corporate Medical Clearance
•    Identify network deficiencies and improper utilization of networks by referring providers
•    Coordinate continuous improvement opportunities & Support project work as needed

What is required?
2+ years related work experience. Experience Details: Clinical nursing; Managed Care
RN – Registered Nurse – State Licensure And/Or Compact State Licensure Current Florida RN license
Proficient Computer skills including use of working with MS Word & MS Excel
Experience with utilization management systems or clinical decision-making tools such as InterQual or Milliman

What we prefer?
Bachelor’s degree Science  (BSN)
Understanding of the managed care/health insurance process
Experience completing utilization review
Experience working with CPT-4 and ICD-9 coding

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.