Legal Nurse Jobs

About The Position

Requirements

• Registered Nurse, currently licensed in Florida.
• Three years of professional nursing experience.
• Proficiency in Microsoft Office, Word, and Excel.
• Knowledge of the State Employees’ PPO Plan, HMO plans and the Prescription Drug Plan.
• Outstanding oral and written communication abilities.
• Understanding of clinical practices and procedures, medical records.
• Knowledge of major medical insurance plan practices.
• Ability to research and compile information and data from a variety of online and other sources.
• Excellent public speaking skills.
• Familiarity with legal proceedings.
• Knowledge of state laws, rules, policies and procedures governing the State Group Insurance Program.
• Knowledge of federal laws and regulations governing or affecting pretax benefit programs, including IRC Section 125, COBRA, Medicare, HIPAA, etc.
• Ability to work independently.
• Ability to establish and maintain effective working relationships with others.
• Knowledge of People First procedures and system.
• Proficient in Microsoft Office suite.
• Outstanding customer service skills.
• Accountability, Communication, Teamwork, Empowerment, Flexibility, Integrity, Respect, Teamwork.

Responsibilities

• Research Level II medical appeals and prepares agency action letters for approval by the division director.
• Research claim disputes and issues benefit determination letters in accordance with applicable rules and benefit provisions.
• Provides testimony for administrative hearings and judicial court cases.
• Responds to routine requests for information and explains policies, procedures and program information to eligible members; uses available resources (plan documents and websites) to educate members about covered services and benefits.
• Recommends improved procedures to submit and review medical claims and to streamline operational processes with third-party plan administrators.
• Establishes, maintains and revises standard operating procedures as needed.
• Provides input to improve language in plan documents, the MyBenefits website, benefits guide, etc.
• Research and coordinates proposed wellness benefits and incentives.
• Recommend strategies for improved member participation.
• Serve as a medical resource for the Division.
• Research and identify wellness benefits and incentives that have provided the greatest ROI of other State government insurance plans.
• Identify long-term and short-term goals and processes to positively impact our health care plans.
• Act as a liaison between the division’s health care and pharmacy providers to increase healthy behaviors and decrease morbidity and mortality among our members.
• Represents the Division at professional meetings and conferences and may be required to prepare and deliver presentations.
• Provides cross-functional support to the Clinical Consultant and other DSGI work units for special projects and peak workload periods as required to support the Division’s operational needs.
• Provides prompt, professional and courteous customer service in response to all inquiries and requests for information received by DSGI.