Florida Blue Medicare - Pre-Service Medical Review Nurse RN

Florida Blue (Blue Cross and Blue Shield of Florida) • FL, FL

11h • $71,200 - $115,700 • Hybrid

About The Position

This position serves as Florida Blue Medicare's clinical expert in working with providers, facilities and subscribers in overseeing the well-being of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.

Requirements

• 2+ years related work experience. Experience Details: Combined experience in utilization management, case management, home health and clinical
• RN - Registered Nurse - State Licensure and/or Compact State Licensure Florida license, Unrestricted
• 1 year utilization management experience
• ICD-9 Coding
• Excellent planning, organizational skills
• Excellent verbal and written communication skills
• Self-starter
• Ability to work independently
• Conflict resolution
• Detail-oriented
• Ability to handle multiple tasks
• Decision making skills
• Flexibility

Nice To Haves

• Basic PC knowledge
• Managed care experience, including InterQual
• Understanding of Regulatory Agencies
• Medicare Advantage experience

Responsibilities

• Review and resolve complex processing issues and utilization management cases, ensuring accurate and timely Medical Review processing of designated Pre-Service healthcare services
• Responsible for more complex review requests. Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests to determine benefit coverage and medical necessity per established criteria meeting compliance standards and timeframes
• Process Pre-Service Medical Review requests received via phone following internal policies and procedures accurately, timely and with attention to detail
• Research requests not clearly meeting established criteria
• Conduct review of subscriber's medical information in order to ensure appropriate benefit administration
• Abstract clinical case presented, review cases and potential denials with the Medical Directors
• Coordinate and maintain complete written documentation on all prior authorization requests
• Provides world class telephone customer service to plan members and/or providers by answering benefit questions, researching and resolving issues and inquiries and ensuring members and providers understand the Company’s products and services
• Conduct training of new staff members and providers as needed

Benefits

• 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
• A comprehensive wellness program
• Competitive pay
• Opportunities for incentive or commission compensation
• Regular annual reviews with pay for performance considerations for base pay increases

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed