Medical Review Nurse RN -Remote

Get To Know US! Guide Well and its family of forward-thinking companies are focused on helping people and communities achieve better health and are at the forefront in the transformation of health care. As a highly integrated care team we empowers members to optimize their health and achieve their health care goals by providing access to quality and affordable health solutions.

Florida Blue, a Guide Well Company, has been providing health insurance to residents of Florida for 75 years. Driven by its mission of helping people and communities achieve better health, the company serves more than five million health care members across the state. We are looking for exceptional people who will bring our mission to life and succeed by putting the member first. What is your impact?

The Medical Review Nurse provides the clinical expertise in working with providers, facilities, and subscribers in overseeing the wellbeing of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.

Apply medical knowledge and expertise in reviewing claims and member/provider inquiries Render medical decisions on post-service claims per established criteria, meeting compliance standards and timeframes Identifies questionable medical practices, existence of medical necessity, and extent of benefit coverage Document findings in various Florida Blue systems Manage medical review inventory, to include resolving workflow problems and identifying

continuous improvement opportunities Identify formal education opportunities and needs for providers and their staff and communicate these needs to appropriate departments Consult with Medical Director and other resources on issues related to claims, member, and provider inquiries/reviews

Current, active, unrestricted Florida RN license 2+ years of clinical nursing experience as a RN Previous Medicare or Managed Care experience, including medical review, or appeals, with experience utilizing established criteria to make medical review determinations Experience working with the following codes: ICD-10, CPT-4, and HCPC Experience working with multiple research/processing systems Experience working with MS Word, Outlook, Excel and PowerPoint What is preferred?

Bachelor of Science in Nursing (BSN) degree Experience with utilization management systems or clinical decision-making tools such as: Medical Coverage Guidelines (MCG), CMS guidelines, and/or Inter Equal Experience working with Florida Blue systems such as: JIVA, Diamond, Quest, Convergence, and/or Siebel Ability to navigate through multiple systems and screens to resolve authorization or medical review requests 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.

What We Offer: As a Florida Blue employee, you will thrive in our Be Well, Work Well, Guide Well 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 includes employer contribution and employer match;

Paid time off, volunteer time off, and 11 holidays 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: $66,400 – $107,900 Typical Annualized Hiring Range: $66,400 – $83,000 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 Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.