Medical Review Nurse (RN)

OpTech • Jacksonville, FL

399d • Hybrid

About The Position

The Medical Review Nurse (RN) at OpTech is responsible for reviewing, authorizing, and coordinating requests for medical services for members. This role involves communication with healthcare providers and members, making decisions based on established medical guidelines, and collaborating with various departments to ensure compliance and efficiency in the prior authorization process.

Requirements

• Knowledge of medical terminology
• Experience with prior authorization
• Experience using nationally recognized criteria, including InterQual
• Knowledge of Medicare regulations and guidelines
• Computer skills, including proficiency in Microsoft Office suite
• Previous experience in a call-center environment
• Ability to navigate multiple systems and screens to resolve requests
• Ability to talk and type simultaneously
• Effective time management skills
• Strong interpersonal and communication skills
• Ability to use electronic medical record and claims systems
• Problem-solving abilities
• Ability to work cooperatively in an interdisciplinary team
• Ability to manage multiple projects and prioritize tasks
• Analytical thinking and decision-making skills
• Ability to manage a large workload

Responsibilities

• Review and authorize phone/fax referral/authorization and clinical form requests per established criteria.
• Determine benefit coverage and medical necessity for requests not approved by non-clinical support representatives.
• Review cases and potential denials with Medical Directors.
• Research requests that do not clearly meet established criteria.
• Assist Prior Authorization non-clinical representatives with the authorization process.
• Coordinate and maintain complete documentation on all prior authorization requests.
• Collaborate with departments such as Claims, UM, Quality, and Disputes/Appeals.
• Log into phone queue to service providers and answer inbound calls regarding authorizations.
• Document contact information in the electronic medical record system.
• Maintain productivity and handle calls professionally.
• Provide accurate prior authorization information to provider offices.

Benefits

• Health and dental benefits from the first day of employment
• Training opportunities
• Flexible/remote work options
• Growth opportunities
• 401K
• Competitive pay

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Industry: Religious, Grantmaking, Civic, Professional, and Similar Organizations
• Education Level: High school or GED