Registered Nurse - Medical Review

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

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