LPN — Utilization Management Admin (Hybrid)

Florida Blue; Jacksonville (FL); Hybrid; USD 52,000 - 85,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability coverage

Retirement plan with employer match

Paid time off and holidays

Wellness program

Job summary

Florida Blue is seeking an Administrative Nurse, LPN to support Clinical Review/Utilization Management processes, including pre-service, post-service, and concurrent medical reviews. The role focuses on member care and adherence to NCQA UM Accreditation standards.

The position offers a hybrid work arrangement with responsibilities ranging from authorization processing to referrals, benefit verification, and collaboration with case management.

Qualifications

• 3+ years related work experience in Clinical, Managed Care, Home Health, Discharge Planning, Utilization Management

Responsibilities

• Process authorization and medical review requests including approvals/denials and denials letters.
• Request additional information via phone, fax, or letter based on Medical Coverage Guidelines and InterQual criteria.
• Verify benefits of requested services and determine provider participation; coordinate with Network for LOAs or Plan to Plan.
• Summarize incomplete requests for medical director review and determine approval/denial with letters.
• Manage census/inventory: identify duplicates, correct surgery dates, fix authorization errors.
• Create authorization requests and referrals to case management and care partners.

Skills

Communication skills

Microsoft Office

Multi-system navigation

Healthcare knowledge

Education

High school diploma or GED

LPN licensure (FL)

Tools

Jiva

InterQual criteria

Job description

Florida Blue is seeking an Administrative Nurse, LPN to support Clinical Review/Utilization Management processes, including pre-service, post-service, and concurrent medical reviews. The role focuses on member care and adherence to NCQA UM Accreditation standards.

The position offers a hybrid work arrangement with responsibilities ranging from authorization processing to referrals, benefit verification, and collaboration with case management.