Registered Nurse - Medical Review

GuideWell Mutual Holding Corporation; United States; Remote; USD 69,000 - 87,000; Full time

Job summary

Join a leading healthcare organization as a Medical Review Nurse. Utilize your clinical expertise to review service requests for Florida Blue members in a remote role. Your responsibilities include making decisions on authorizations, collaborating with providers, and ensuring compliance with policies. This position requires a Registered Nurse license and offers a supportive work culture with comprehensive benefits and competitive pay.

Benefits

Medical, dental, and vision insurance

Retirement Savings Plan with employer match

Paid time off and volunteer time off

Comprehensive wellness program

Qualifications

• 2+ years related work experience required.
• Registered Nurse License required.
• Experience with Medicare or Managed Care preferred.

Responsibilities

• Review and authorize service requests for Florida Blue members.
• Determine benefit coverage and medical necessity for authorization requests.
• Collaborate with various departments regarding authorizations.

Skills

Clinical expertise

Communication

Critical thinking

Proficient in MS Office Products

Education

High school diploma or GED

Bachelor’s degree

RN - Registered Nurse License

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.