Medical Review Nurse (RN)

Position Overview

Our Client, a Mutual Insurance Holding company, is looking for a Medical Review Nurse (RN) for their Remote location.

Key Responsibilities

• Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests per established criteria meeting compliance standards and timeframes
• Review all requests not approved by the non-clinical support representative 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 representatives with the Prior Authorization process
• Coordinate and maintain complete written documentation on all prior authorization 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
• Provide accurate prior authorization information to provider offices

Required Qualifications

• 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 a large workload
• 0-2 years related work experience
• High School Diploma or GED
• RN - Licensed Practical Nurse - State Licensure

Benefits & Perks

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities

As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, gender, sexual orientation, gender identity or expression, ethnicity, national origin, age, disability status, political affiliation, genetics, marital status, protected veteran status, or any other characteristic protected by federal, state, or local laws.