Medical Review Nurse RN

Join the movement transforming healthcare. GuideWell and its family of companies, including Florida Blue, are revolutionizing the way people and communities achieve better health. As a trailblazer in the industry, we're empowering millions of members to take control of their health and wellness. With a 75-year legacy of providing top-notch, affordable health solutions, we're looking for passionate and driven individuals to join our team. If you're ready to make a real difference in the lives of others, we want you to bring your unique energy and expertise to our mission-driven organization. Apply now and be part of shaping the future of healthcare!

What Is My Impact?
The Medical Review Nurse 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. The nurse also refers cases to Florida Blue medical directors for benefit and medical necessity determination. This role requires rotational on-call, holiday and weekend work.

The Key Responsibilities:

• Apply clinical knowledge and expertise to review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests utilizing established criteria, while meeting compliance standards and timeframes.
• Review authorization requests to determine benefit coverage and medical necessity.
• Refers authorization requests and refers requests not clearly meeting established criteria to the Medical Director.
• Provide coverage of provider facing phone queue.
• Answer inbound and place outbound calls regarding authorizations within established time frame.
• Complete benefit and medical necessity reviews using clinical information obtained verbally.
• Maintain written documentation of verbal communication with providers/Members.
• Provide accurate prior authorization information to provider offices.
• Collaborate with other Florida Blue departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors.

Important To Know:

This position requires flexibility in scheduling, including on-call responsibilities that may fall on holidays, weekends, and overnight shifts. The selected candidate will be expected to be available during our standard hours of 8:00 AM - 6:30 PM EST, with assigned shifts that may vary within these hours. Additionally, this role involves rotational weekend work, requiring the selected candidate to be available to work on weekends as scheduled.

What Is REQUIRED:

• 2+ years related current work experience to include medical review/prior authorization as well as an understanding of Regulatory Agencies, such as NCQA Experience with utilization management systems or clinical decision-making tools such as: Medical Coverage Guidelines (MCG) and CMS guidelines
• Experience working with MS Office Products (Outlook, Word, Excel and/or PowerPoint)
• Proficient with using desktop/laptop, navigating multiple systems/screens to conduct research, access information and document reviews
• Excellent written and verbal communication skills
• Ability to work rotational on call, including weekends, holidays and overnight; ability to work any shift within core business hours 8:00 am - 6:30 pm EST/EDT; ability to work rotational weekends

Required Licenses and Certifications:

• RN - Registered Nurse - State Licensure and/or Compact State Licensure

What Is Preferred:

• Medicare prior authorization
• Previous Medicare or Managed Care experience
• Experience working with one or more of the following coding systems: ICD-10, CPT-4 and HCPCS
• InterQual
• Call center 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.

Physical/Environmental Activities:
Must be able to occasionally travel to multiple locations for work (i.e. travel to attend meetings, events, conferences).

What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

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 as well as 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.

Typical Annualized Hiring Range: $69,400 - $86,800 (This is the set range that a candidate will be hired into)

Annualized Salary Range: $69,400 - $112,800 (This is to show the long-term financial growth of this position)

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.