Pre/Post Service Medical Review Nurse RN
 Spectraforce Technologies | |
 United States, Florida, Jacksonville | |
 Feb 26, 2025 | |
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Job Title: Pre/Post Service Medical Review Nurse RN
Duration: 3 Months with possibility of extension Location: Remote - Florida Shift :Shift: M-F (8-5) some weekend work, however if a weekend day is worked they can flex on their weekday shifts (no more than 40 hrs./week) Must: * Previous CMS experience and review of all organization determinations, including pharmacy reviews. * Top candidates are those that have Jiva, Seibel, and Diamond experience. * Must have a FL RN License - Unrestricted or Nursing Compact license Job Summary: This position serves as client Medicare's 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. Required Qualifications: * 3+ years related work experience * Combined experience in utilization management, case management, home health and clinical Education Level: * RN - Registered Nurse - State Licensure And/Or Compact State Licensure * Florida license, Unrestricted Additional Required 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 Preferred: * Ability to work with multiple screens and systems * Managed care experience, Including InterQual, NCD and LCD medical review criteria * Understanding of Regulatory Agencies * Medicare Advantage Experience * Prior FLBL experiencePosition is offered by a no fee agency. | |