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- Apply medical knowledge and expertise in reviewing claims, authorization requests, and subscriber/ provider inquiries
- Render medical decisions on pre-service requests and 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 and render medical decision 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
- Conducts telephonic reviews with ability to cover phones between 8am and 6pm daily.
- Follow regulatory requirements
- Project work as needed
- Moderate to heavy keying required