Medical Review Nurse RN

Blue Cross Blue Shield Of Florida Miami , FL 33196

Posted 1 week ago

  • Job Summary

  • Job duties include but not limited to the following:

  • Apply medical knowledge and expertise in reviewing claims, and subscriber/ provider inquiries

  • Render medical decisions on 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

  • Follow regulatory requirements

  • Project work as needed

  • Moderate to heavy keying required

Job Requirements:

  • Current, active, unrestricted Florida license RN

  • BS in Nursing

  • 2 years of clinical nursing experience as an RN

  • Previous Medicare or Managed Care experience, including medical review, or appeals, with experience utilizing established criteria to make medical review determinations

  • Experience working with one or more of the following coding systems: ICD-9, ICD-10, CPT-4 and HCPC coding

  • Excellent written and verbal communication skills

  • Experience working with multiple research/processing systems

  • Experience working with MS Word, Excel and PowerPoint

Business Specific Criteria (preferred skills):

  • BS in Nursing

  • Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual

  • Experience working with BCBSF systems such as: JIVA, Diamond, Quest, and Siebel

  • Experience with Medicare review using CMS guidelines (e.g. NCD, LCD, and IOM's)

  • Ability to navigate through multiple systems and screens to resolve authorization or medical review requests

  • Effective time management skills

  • Work cooperatively, positively, and collaboratively in an interdisciplinary team

  • 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

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Medical Review Nurse RN

Blue Cross Blue Shield Of Florida