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JobsRUs.com. is seeking to hire a Licensed practical nurse OR Medical Review Nurse for our client in Jacksonville, FL!
Benefits Available!
Weekly Pay!
$34.48/Hour

JOB SUMMARY
The Medical Review Nurse LPN reviews, authorizes, coordinates, and responds to requests for services for Florida Blue members. This position also communicates telephonically with providers and their offices, and occasionally with members. Makes decisions based on established policies and procedures, Florida Blue medical coverage guidelines, benefits, InterQual criteria, nursing knowledge. Refers cases to Florida Blue medical directors for potential denial.

Essential Functions
Perform medical record reviews to support improvement and compliance, abstract HEDIS data, to include over-read of reviews, working collaboratively with internal HEDIS STARs Team and the Quality Team.
Perform administrative functions to include; medical record request, faxing and calls to members and providers as needed. Maintain organized, updated reporting of activities with clear documentation. Required to track, monitor and report on the status of records and volume of work.
Complete claim research to identify the service performed, dates of service, provider type, and place of service. Research may include multiple systems and reports.
Must have previous medical record / quality review experience; HEDIS/STARS preferred
Must be proficient in Microsoft Office (Word, Excel, Outlook, and PowerPoint) as well as Internet research skills
Ability to communicate clearly verbally and in writing
Organizational skills are very important; must be able to work independently to complete tasks with minimal direction.
Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests per established criteria meeting compliance standards and time frames
Review all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity
Review cases and potential denials with the Medical Directors
Research requests not clearly meeting established criteria
Assist the Prior Authorization non-clinical reps with the Prior Authorization process
Coordinate and maintain complete written documentation on all prior authorizations requests.
Collaborate with other Florida Blue departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors.
Log into phone queue to service providers
Answer inbound calls regarding authorizations within established time frame
Document contact information in electronic medical record system
Maintain productivity
Handle calls professionally
Provide accurate prior authorization information to provider offices

Job Requirements
Knowledge of medical terminology
Experience with prior authorization
Experience applying nationally recognized criteria, including InterQual
Knowledge of Medicare regulations and guidelines
Computer skills, including ability to use Microsoft Office suite
Previous experience within a call-center environment
Ability to navigate through multiple systems and screens to resolve authorization or medical review requests
Talking and typing simultaneously
Effective time management skills
Effective interpersonal and communication skills
Ability to use electronic medical record and claims systems
Problem solving abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Work respectfully and positively with others
Ability to manage multiple projects and prioritize work tasks to adhere to deadlines and identified time frames
Ability to think analytically and make decisions
Ability to manage large workload

Preferred
Disease management experience is helpful
Recent experience in medical record reviews, data collection for HEDIS / Stars

Required Experience:
2+ years related work experience

Required Education:
High School Diploma or GED

Required Licenses and Certifications
LPN - Licensed Practical Nurse - State Licensure

Previous HEDIS experience required for role
Prior FL Blue HEDIS experience highly preferred