Medical Review Nurse Needed
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POST DATE 8/21/2016
END DATE 12/15/2016
JOB DESCRIPTIONWork Schedule: M-F, 8:00 a.m. - 5:00 p.m.
Temp to Perm
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 claims, identifying questionable medical practices, existence of medical necessity, level of reimbursement and extent of benefit coverage
*Document findings and render medical decision in various BCBSF systems
*Manage medical review inventory, to include resolving workflow problems and identifying medical cost savings
*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
*Follow regulatory requirements
*Project work as needed
*Moderate to heavy keying required
*Current, active Florida RN license
*2+ years of clinical nursing experience as an RN
*Excellent written and verbal communication skills
Business Specific Criteria (preferred skills):
*Bachelors degree in Nursing
*Certified Professional Coder
*Experience working with ICD-9, CPT-4 and HCPC coding
*Experience completing utilization review
*Experience with utilization management systems [Quest, Diamond, Convergence X, JIVA, CMCA, EIP) or clinical decision making tools such as InterQual, Medical Coverage Guidelines (MCG)
*Experience working with multiple research/processing systems
*Experience working with MS Word, Excel and PowerPoint
We are an equal employment opportunity employer and will consider all qualified candidates without regard to disability or protected veteran status.