Description:This position serves as BCBSFs clinical expert in working with providers, facilities and subscribers in overseeing the wellbeing of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.Essential functions: Conduct onsite review of subscribers medical information in order to ensure appropriate benefit administration. Consult with providers, facilities staff, subscribers and their families to ensure cost efficiencies in the delivery of care. Coordinate with internal and external sources in the ongoing management of subscribers care.Gather and review subscribers medical information in order to schedule, based on criticality, onsite reviews. Apply clinical expertise in the completion of subscribers medical documentation, which become legal documents and part of subscribers file.Conduct weekly reviews with internal and external sources on the care and services provided by BCBSF to subscribers. Compile weekly, monthly and quarterly reports used to determine cost savings, identify process improvement opportunities and document activities.Conduct training of new staff members and providers as needed.Job Requirements:1year of utilization management experienceICD9 CodingExcellent planning, organizational skillsExcellent verbal and written communication skillsSelfstarterAbility to work independentlyConflict resolutionDetail orientedAbility to handle multiple tasksDecision making skillsFlexibilityBasic PC knowledgeManaged care experienceUnderstanding of Regulatory AgenciesExperience: 3 years related work experience or equivalent combination of transferable experience and educationCombined experience in utilization management, case management, home health and clinicalEducation: Nursing Related Bachelors degree requiredQualificationsCertificates: Florida license NursingRN Registered Nurse State Licensure AndOr Compact State LicensureFlorida license NonClinicalAZDL Driver License Valid And In StateJob Title: PreService Medical Review Nurse RNJob Summary:This position serves as Florida Blue Medicares clinical expert in working with providers, facilities and subscribers in overseeing the well being of subscribers while ensuring the proper administration of benefits, cost effectiveness, and the coordination of the delivery of quality care.Essential Functions: The essential functions listed represent the major duties of this role, additional duties may be assigned. Review and resolve complex processing issues and utilization management cases, ensuring accurate and timely Medical Review processing of designated PreService healthcare services Responsible for more complex review requests. Review and authorize, as appropriate, phonefax referralauthorization and clinical form requests to determine benefit coverage and medical necessity per established criteria meeting compliance standards and timeframes Process PreService Medical Review requests received via phone following internal policies and procedures accurately, timely and with attention to detail Research requests not clearly meeting established criteria Conduct review of subscribers medical information in order to ensure appropriate benefit administration. Abstract clinical case presented, review cases and potential denials with the Medical Directors Coordinate and maintain complete written documentation on all prior authorizations requests. Provides world class telephone customer service to plan members andor providers by answering benefit questions, researching and resolving issues and inquiries and ensuring members and providers understand the Companys products and services Conduct training of new staff members and providers as needed.Required Qualifications: 3 years related work experience Combined experience in utilization management, case management, home health and clinicalEducation Level: RN Registered Nurse State Licensure AndOr Compact State Licensure Florida license, UnrestrictedAdditional Required Qualifications: 1 year utilization management experience ICD9 Coding Excellent planning, organizational skills Excellent verbal and written communication skills Self starter Ability to work independently Conflict resolution Detail oriented Ability to handle multiple tasks Decision making skills FlexibilityPreferred: Ability to work with multiple screens and systems Managed care experience, Including InterQual, NCD and LCD medical review criteria Understanding of Regulatory Agencies Medicare Advantage Experience Prior FLBL experienceMust: Previous CMS experience and review of all organization determinations, including pharmacy reviews. Top candidates are those that have Jiva, Seibel, and Diamond experience. Remote Florida Must have a FL RN License Unrestricted or Nursing Compact licenseShift: MF 85 some weekend work, however if a weekend day is worked they can flex on their weekday shifts no more than 40 hrs.week

Position is offered by a no fee agency. 

Location : 4800 Deerwood Campus Parkway, Building 100, Jacksonville, Florida, United States, 32246 
About Us: Established in 2004, SPECTRAFORCE® is one of the largest and fastest-growing diversity-owned staffing firms in the US. The growth of our company is a direct result of our global client service delivery model that is powered by our state-of-the-art A.I. proprietary talent acquisition platform, robust ISO 9001:2015/ISO 27001 certified processes, and strong and passionate client engaged teams. We have built our business by providing talent and project-based solutions, including Contingent, Permanent, and Statement of Work (SOW) services to over 140 clients in the US, Canada, Puerto Rico, Costa Rica, and India. Key industries that we service include Technology, Financial Services, Life Sciences, Healthcare, Telecom, Retail, Utilities and Transportation. SPECTRAFORCE is built on a concept of “human connection,” defined by our branding attitude of NEWJOBPHORIA®, which is the excitement of bringing joy and freedom to the work lifestyle so our people and clients can reach their highest potential. Learn more at: http://www.spectraforce.com
 
Benefits: SPECTRAFORCE offers ACA compliant health benefits as well as dental, vision, accident, critical illness, voluntary life, and hospital indemnity insurances to eligible employees. Additional benefits offered to eligible employees include commuter benefits, 401K plan with matching, and a referral bonus program. SPECTRAFORCE provides unpaid leave as well as paid sick leave when required by law.

Equal Opportunity Employer: SPECTRAFORCE is an equal opportunity employer and does not discriminate against any employee or applicant for employment because of race, religion, color, sex, national origin, age, sexual orientation, gender identity, genetic information, disability or veteran status, or any other category protected by applicable federal, state, or local laws. Please contact Human Resources at LOA@spectraforce.com if you require reasonable accommodation.
 
California Applicant Notice: SPECTRAFORCE is committed to complying with the California Privacy Rights Act (“CPRA”) effective January 1, 2023; and all data privacy laws in the jurisdictions in which it recruits and hires employees. A Notice to California Job Applicants Regarding the Collection of Personal Information can be located on our website. Applicants with disabilities may access this notice in an alternative format by contacting NAHR@spectraforce.com.
 
LA County, CA Applicant Notice: If you are selected for this position with SPECTRAFORCE, your offer is contingent upon the satisfactory completion of several requirements, including but not limited to, a criminal background check. We consider qualified applicants with arrest or conviction records for employment in accordance with all local ordinances and state laws, including the Los Angeles County Fair Chance Ordinance for Employers (FCO) and the California Fair Chance Act (FCA). The background check assessment will consider whether a criminal history could reasonably have a direct, adverse impact on the job-related safety, security, trust, regulatory compliance, or suitability for this role. Such findings may result in withdrawal of a conditional job offer. 


At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $9.50/hr.