Medical Review Nurse RN

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 and medical necessity determination. This role requires rotational on-call, holiday and weekend work.

Important to Know

•  Core business hours are between 8:00am - 6:30pm with variable shift hours working a 40hr work week.
• Remote opportunity with required rotational weekend on call hours.

• Must have RN - Registered Nurse - State Licensure And/Or Compact State Licensure 

   

What Will You Be Doing

• Apply clinical knowledge and expertise to review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests utilizing established criteria, while meeting compliance standards and timeframes
• Review authorization requests to determine benefit coverage and medical necessity (20%)
• Refers authorization requests and refers requests not clearly meeting established criteria to the Medical Director (20%)
• Provide coverage of provider facing phone queue
• Answer inbound and place outbound calls regarding authorizations within established time frame
• Complete benefit and medical necessity reviews using clinical information obtained verbally
• Maintain written documentation of verbal communication with providers/Members
• Provide accurate prior authorization information to provider offices 
• Collaborate with other Florida Blue departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors. 
• Requires on-call work, including holidays, weekends and overnight
   

What You Must Have

• 2+ years related work experience

• High school diploma or GED 

• Required RN - Registered Nurse - State Licensure And/Or Compact State Licensure 

• Excellent written and verbal communication skills 

• Proficient with using desktop/laptop, navigating multiple systems/screens to conduct research, access information and document reviews 

• Experience working with MS Office Products (Outlook, Word, Excel and/or PowerPoint) 

• Ability to work rotational on call, including weekends, holidays and over night; ability to work any shift within core business hours 8:00 am - 6:30 pm EST/EDT; ability to work rotational weekends

What We Prefer

• Bachelor’s degree 

• 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 HCPCS 

• Understanding of Regulatory Agencies, such as NCQA Experience with utilization management systems or clinical decision-making tools such as: Medical Coverage Guidelines (MCG), CMS guidelines, and/or InterQual Call center experience
   

General Physical Demands
 

• Exerting up to 10 pounds of force occasionally to move objects. 

• Jobs are sedentary if traversing activities are required only occasionally. 

• Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). 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 including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• 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. 

Targeted Offer Salary Range: $69,400 - $112,800

Typical Annualized Hiring Range: $69,400 - $86,800

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 Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.