Job Summary:

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

• 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: Florida Licensed Practical Nurse (LPN)