Seeking a Pre-Service Medical Review Nurse RN for a 100% Remote position but must reside and be licensed in Florida.

This position serves as a clinical expert in working with providers, facilities and subscribers in overseeing the well being of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.

Essential functions

• The essential functions listed represent the major duties of this role, additional duties may be assigned.
• Review and resolve complex processing issues and utilization management cases, ensuring accurate and timely Medical Review processing of designated Pre-Service healthcare services
• Responsible for more complex review requests. Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests to determine benefit coverage and medical necessity per established criteria meeting compliance standards and timeframes
• Process Pre-Service Medical Review requests received via phone following internal policies and procedures accurately, timely and with attention to detail
• Research requests not clearly meeting established criteria
• Conduct review of subscriber's medical information in order to ensure appropriate benefit administration.
• Abstract clinical case presented, review cases and potential denials with the Medical Directors
• Coordinate and maintain complete written documentation on all prior authorizations requests.
• Provides world class telephone customer service to plan members and/or providers by answering benefit questions, researching and resolving issues and inquiries and ensuring members and providers understand the Company’s products and services
• Conduct training of new staff members and providers as needed.

Job Requirements

• Experience in or working knowledge of HEDIS, Medicare Stars and Quality Rating Systems
• Knowledge of Compliance Standards and regulatory guidelines such as national Committee for Quality Assurance (NCQA), Center for Medicare/Medicaid Services (CMS).
• Internet research skills, intermediate or higher level of Microsoft Office proficiency (Word, Excel, Outlook, and PowerPoint).
• Ability to travel up to 20% including overnight.
• Ability to communicate verbally and in writing clearly and succinctly to a wide audience including Executive Leadership
• Four years of related work experience.
• Health Policy and Health Insurance Industry experience.
• Project Management Experience.

Qualifications

• 1 year utilization management experience
• ICD-9 Coding
• Excellent planning, organizational skills
• Excellent verbal and written communication skills
• Self starter
• Ability to work independently
• Conflict resolution
• Detail oriented
• Ability to handle multiple tasks
• Decision making skills
• Flexibility

Required Experience

• 3+ years related work experience
• Combined experience in utilization management, case management, home health and clinical
• Previous CMS experience and review of all organization determinations, including pharmacy reviews.
• Understanding of Regulatory Agencies
• Medicare Advantage Experience
• Top candidates are those that have Jiva, Seibel, and Diamond experience.

Qualifications/Certificates

• Registered Nurse
• State Licensure And/or Compact State Licensure
• Florida license, Unrestricted or Nursing Compact license