Medical Review RN (State of FL)

OpTech is a leading Talent Management and Technology Services company with nearly two decades years of successful experience managing large, enterprise-wide solutions for our clients. We provide mission critical services to major commercial clients including well known institutions in financial services, healthcare /insurance , utilities and manufacturing. OpTech has contracts with the Federal Government supporting agencies such as the Department of Homeland Security, Department of Defense, and the Department of Labor. OpTech has been nationally recognized for “Excellence in Staffing”, National “Best and Brightest Companies to Work For”, and “Top 500 Woman Owned Businesses in the United States”. At OpTech we believe that “Talent” matters. We are committed to connecting great companies with great talent to creatively and effectively apply technology to solve important problems.

Great opportunity for a Register Nurse - Medical Review Nurse (State of FL license required) Remote opportunity: 3 month contract, high probability of extension Must have Active/Valid Register Nurse license with the State of Florida Compensation: $34/hour - $36.00/ hour; Ability to work weekend/holiday hours on rotation JOB SUMMARY The Medical Review Nurse RN reviews, authorizes, coordinates, and responds to requests for services for Florida Blue members. This position also 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, InterQual criteria, nursing knowledge. Refers cases to Florida Blue medical directors for potential denial.

Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests per established criteria meeting compliance standards and timeframes Review all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity Review cases and potential denials with the Medical Directors Research requests not clearly meeting established criteria Assist the Prior Authorization non-clinical reps with the Prior Authorization process Coordinate and maintain complete written documentation on all prior authorizations requests. Collaborate with other Florida Blue departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors. Log into phone queue to service providers Answer inbound calls regarding authorizations within established time frame Provide accurate prior authorization information to provider offices Handle calls professionally Document contact information in electronic medical record system Maintain productivity