Registered Nurse - Medical Review

Florida Blue; United States; Remote; USD 69,000 - 87,000; Full time

Job summary

A leading health insurance company is seeking a Medical Review Nurse to utilize clinical expertise in reviewing and authorizing service requests. This role includes communicating with providers, making informed decisions based on guidelines, and collaborating with various departments. The position offers a remote opportunity with a competitive salary range and comprehensive benefits.

Benefits

Medical, dental, and vision insurance

Income protection benefits

Retirement Savings Plan including employer match

Paid time off and holidays

Comprehensive wellness program

Qualifications

• 2+ years related work experience required.
• RN - Registered Nurse - State Licensure or Compact State Licensure.
• Proficient with desktop/laptop for navigation.

Responsibilities

• Review and authorize service requests for members.
• Communicate with providers and members regarding authorizations.
• Collaborate with departments like Claims, UM, and Quality.

Skills

Clinical expertise

Communication

Analytical skills

Education

High school diploma or GED

RN - Registered Nurse - State Licensure

Bachelor’s degree (preferred)

Tools

MS Office Products

Job description

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Job Description

Join our team as a Medical Review Nurse and utilize your clinical expertise to review and authorize service requests for Florida Blue members. This role involves communicating with providers and members, making decisions based on established policies and guidelines, and referring cases to medical directors as needed.

Job Description

Join our team as a Medical Review Nurse and utilize your clinical expertise to review and authorize service requests for Florida Blue members. This role involves communicating with providers and members, making decisions based on established policies and guidelines, and referring cases to medical directors as needed.

Important to Know

• Remote opportunity with required rotational weekend on call hours. Core business hours are between 8:00am - 6:30pm with variable shift hours working a 40hr work week.
• 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
• Refers authorization requests and refers requests not clearly meeting established criteria to the Medical Director
• Answer inbound and place outbound calls regarding authorizations within established time frame
• 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
  
  

What You Must Have

• 2+ years related work experience
• High school diploma or GED
• RN - Registered Nurse - State Licensure and/or Compact State Licensure
• 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
  
  

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
• 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.
  
  

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.

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

Annualized Salary Range:$69,400 - $112,800

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.

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Insurance

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