Florida Blue

Registered Nurse - Medical Review

Posted on

June 9, 2025

Job Type

Full-Time

Role Type

Care Management

License

RN

State License

Compact / Multi-State

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Company Description

Job Description

Join our team as a Medical Review Nurse and utilize your clinical expertise to review and authorize service requests for Florida Blue members. This role involves communicating with providers and members, making decisions based on established policies and guidelines, and referring cases to medical directors as needed. Important to Know: Remote opportunity with required rotational weekend on call hours. Core business hours are between 8:00am - 6:30pm with variable shift hours working a 40hr work week. Registered Nurse State Licensure and/or Compact State Licensure

Requirements

2+ years related work experience High school diploma or GED RN - Registered Nurse - State Licensure and/or Compact State Licensure Proficient with using desktop/laptop, navigating multiple systems/screens to conduct research, access information and document reviews Experience working with MS Office Products (Outlook, Word, Excel and/or PowerPoint) Ability to work rotational on call, including weekends, holidays and over night; ability to work any shift within core business hours 8:00 am - 6:30 pm EST/EDT What We Prefer: Bachelor’s degree Previous Medicare or Managed Care experience, including medical review, prior authorization, or appeals, with experience utilizing established criteria to make medical review determination Experience working with one or more of the following coding systems: ICD-10, CPT-4 and HCPCS Understanding of Regulatory Agencies such as NCQA Experience with utilization management systems Clinical decision-making tools such as: Medical Coverage Guidelines (MCG), CMS guidelines, and/or InterQual Call center experience General Physical Demands: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

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Responsibilities

Apply clinical knowledge and expertise to review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests utilizing established criteria, while meeting compliance standards and timeframes Review authorization requests to determine benefit coverage and medical necessity Refers authorization requests and refers requests not clearly meeting established criteria to the Medical Director Answer inbound and place outbound calls regarding authorizations within established time frame Provide accurate prior authorization information to provider offices Collaborate with other Florida Blue departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors

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