Medical Review Nurse RN-Remote - Med Surg

Medical Review Nurse RN-Remote Are YOU ready to expand your nursing career where you can achieve work life balance? If so, read on and get ready to Apply! We offer benefits, work-life balance, flexible work arrangements, opportunities for growth and development, and a great place to work across our enterprise! What will you be doing: The incumbent will be applying their medical knowledge and expertise in reviewing claims, and subscriber/ provider inquiries. What will be your purpose: * 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 What we require: * Current, active, unrestricted Florida RN license * Associate of Science in Nursing degree * 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 What we prefer: * Bachelor of Science in Nursing (BSN) degree * 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 * 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 General Physical Demands Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.

About the Company:
Blue Cross Blue Shield of Florida