Medical Review Nurse (RN)
: Job Details :

Reviews, authorizes, coordinates, and responds to requests for services for Florida Blue members. Communicates telephonically with providers and their offices, and occasionally with members. Makes decisions based on established policies and procedures, Florida Blue medical coverage guidelines, benefits, Inter. Qual criteria, and nursing knowledge. Refers cases to Florida Blue medical directors for potential denial. Reviews and authorizes phone/fax referral/authorization and clinical form requests per established criteria meeting compliance standards and timeframes. Reviews all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity. Reviews cases and potential denials with the Medical Directors. Researches requests not clearly meeting established criteria. Assists the Prior Authorization non-clinical reps with the Prior Authorization process. Cordiates and maintains complete written documentation on all prior authorizations requests. Co...Medical, Medical Director, Nurse, Authorization, Practical Nurse, Healthcare, Staffing