Pre / Post Service Medical Review Nurse RN

Integrated Resources, Inc.; Jacksonville (FL); Remote; USD 60,000 - 80,000; Full time

Job summary

A leading healthcare organization in Jacksonville is seeking a Pre / Post Service Medical Review Nurse RN to oversee the well-being of subscribers and ensure effective care delivery. Your role includes reviewing medical information, consulting with providers, and producing essential reports to promote cost efficiency. Qualified candidates should have a Bachelor's in Nursing, active Florida RN license, and experience in utilization management. This position is crucial for maintaining high-quality care and compliance with regulatory standards.

Qualifications

• 1-year of utilization management experience.
• 3+ years related work experience or equivalent combination of transferable experience and education.
• Florida RN License - Unrestricted or Nursing Compact license.

Responsibilities

• Conduct on-site review of subscriber's medical information.
• Consult with providers and facilities staff to ensure cost-effective care.
• Compile reports to identify cost savings and process improvements.

Skills

ICD-9 Coding

Planning

Organizational skills

Communication

Detail oriented

Ability to handle multiple tasks

Flexibility

Basic PC knowledge

Managed care experience

Education

Nursing related Bachelor's degree

Job description

Job Title : Pre / Post Service Medical Review Nurse RN

Job Location : Jacksonville, FL

Job Duration : 2-3 Months (Possibilities of Extension)

Shift : Monday - Friday, 8 : 00am - 5 : 00pm

Job Summary :

• This position serves as Client's clinical expert in working with providers, facilities and subscribers in overseeing the wellbeing of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.

Essential functions :

• Conduct on-site review of subscriber's medical information in order to ensure appropriate benefit administration.
• Consult with providers, facilities' staff, subscribers and their families to ensure cost efficiencies in the delivery of care.
• Coordinate with internal and external sources in the on-going management of subscriber's care.
• Gather and review subscriber's medical information in order to schedule, based on criticality, on-site reviews.
• Apply clinical expertise in the completion of subscriber's medical documentation, which become legal documents and part of subscriber's file.
• Conduct weekly reviews with internal and external sources on the care and services provided by Client to subscribers.
• Compile weekly, monthly and quarterly reports used to determine cost savings, identify process improvement opportunities and document activities.
• Conduct training of new staff members and providers as needed.

Job Requirements :

• 1-year of utilization management experience.
• ICD-9 Coding
• Excellent planning, organizational skills.
• Excellent verbal and written communication skills.
• Ability to work independently
• Detail oriented
• Ability to handle multiple tasks
• Flexibility
• Basic PC knowledge
• Managed care experience
• Understanding of Regulatory Agencies

Education :

• Nursing - Related Bachelor's degree required.

Experience :

• 3+ years related work experience or equivalent combination of transferable experience and education.
• Combined experience in utilization management, case management, home health and clinical.

Certifications :

• Florida license - NursingRN - Registered Nurse - State Licensure And / Or Compact State Licensure.
• Florida license - Non-ClinicalAZDL - Driver License - Valid And In State.

Preferred Skills :

• Ability to work with multiple screens and systems
• Managed care experience, Including InterQual, NCD and LCD medical review criteria.
• Understanding of Regulatory Agencies
• Prior FLBL experience

Must Skills :

• Previous CMS experience and review of all organization determinations, including pharmacy reviews.
• Top candidates are those that have Jiva, Seibel, and Diamond experience.
• Remote - Florida.
• Must have a FL RN License - Unrestricted or Nursing Compact license.

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Medical Review Nurse • Jacksonville, FL, US