Pre-Authorization Medical Review Nurse Position Available In Volusia, Florida

This position is Remote within the state of Florida

POSITION SUMMARY

The Pre-Authorization Medical Review Nurse performs initial clinical review on cases received from Providers and Members that require prior authorization or pre-certification. The Pre-Authorization Medical Review Nurse reviews each Member’s benefit package for coverage, limitations, and exclusions. They gather pertinent medical records, obtain clinical support guidelines, and then compare the guidelines to the medical records to determine if appropriate clinical indications are met. They approve cases when medical necessity guidelines and benefits are met or prepare case files for review by the Utilization Management (UMP). Assists the Utilization Management Physician with case review and assists Non-Clinical Staff with Provider/member notifications on denials of service. The Nurse will be involved in the transition of care process to assure a smooth transition to FHCP and assist new member navigation through the system.

QUALIFICATIONS

Education, skills and experience:

• Current licensure in Florida as a Licensed Practical Nurse.
• Minimum of 2 years clinical experience required. Acceptable areas of experience include physician office nursing, Medical Surgical, Pediatrics, OB, ER, ICU, SNF/ALF or Hospice.
• Referral prior authorization, pre-certification experience preferred.
• Previous experience with Case Management, authorization of services or utilization review preferred.
• Knowledge of Medicare criteria and/or other nationally recognized criteria’s preferred.
• Possess good oral and written communication skills.
• Exposure to working with an electronic health record system required.
• Working knowledge of medical coding preferred.
• Strong computer skills and knowledge of Microsoft Word and Outlook preferred.
• Keyboarding skills of at least 20 wpm required.
• Strong telephone, oral communication, customer service and critical thinking skills are required.