Seeking an LPN Medical Review Nurse for a position in Largo, Florida. Must be licensed in Florida.

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.

Responsibilities

• 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 time frames
• 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 authorization’s 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

Requirements

• Experience applying nationally recognized criteria, including InterQual
• Ability to navigate through multiple systems and screens to resolve authorization or medical review requests
• Must have previous medical record / quality review experience; HEDIS/STARS preferred
• Disease management experience is helpful
• Maintaining proficiency in equipment usage in assigned departments.
• Completing the relevant portions of the Encounter form using correct CPT (Current Procedural Terminology) and ICD-10 (International Classification of Diseases).
• Ensuring the clinical area is stocked for patient care needs.
• Adhering to Pathology Labeling and Processing policy.

Required Experience

• 2+ years of related work experience
• Active Florida LPN License

Required Education

• High School Diploma or GED

Required Licenses and Certifications

• LPN