Florida Blue Medicare - Pre-Service Medical Review Nurse RN

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. Job duties include but are not limited to: • 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 Job 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 Preferred: • Basic PC knowledge • Managed care experience, including InterQual • Understanding of Regulatory Agencies • Medicare Advantage experience General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. This position offers a hybrid work arrangement which combines flexibility with in-office engagement. Team schedules are determined based on role requirements and business needs. Travel to and from our corporate or regional offices may be required. What We Offer: As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living. 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. Annualized Salary Range: $71,200 - $115,700 Typical Annualized Hiring Range: $71,200 - $89,000 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.