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Location

Daytona Beach, FL | United States

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Job description

LPN PRE-Authorization Medical Review Nurse REMOTE Referrals Full-time 1st shift Monday - Friday 8am - 5pm

Remote Within Our Coverage Area of Volusia, Flagler, Seminole, Brevard, and St. Johns Counties

POSITION SUMMARY:

The Pre-Authorization Medical Review Nurse performs initial clinical review on cases received from Providers and Members that require prior authorization or pre-certification. The Nurse reviews each Member's benefit package for coverage, limitations, and exclusions. They gather pertinent medical records, obtain clinical support guidelines, and then compare the guidelines to the medical records to determine if appropriate clinical indications are met. They approve cases when medical necessity guidelines and benefits are met or prepare case files for review by the Utilization Management Physician (UMP). Assists the UMP with case review and assists Non-Clinical Staff with Provider/Member notifications on denials of service. The Nurse will be involved in assisting with the transition of care process for a new member to assure a smooth transition and navigation through the system.

QUALIFICATIONS:

Education, skills and experience:

• Current licensure in Florida as a Licensed Practical Nurse.
• Minimum of 2 years clinical experience required. Acceptable areas of experience include physician office nursing, Medical Surgical, Pediatrics, OB, ER, ICU, SNF/ALF or Hospice.
• Referral prior authorization, pre-certification experience preferred.
• Previous experience with Case Management, authorization of services or utilization review preferred.
• Knowledge of Medicare criteria and/or other nationally recognized criteria preferred.
• Possess good oral and written communication skills.
• Exposure to working with an electronic health record system required.
• Working knowledge of medical coding preferred.
• Strong computer skills and knowledge of Microsoft Applications, Word and Outlook required.
• Keyboarding skills of at least 30 wpm required.

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Job tags

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Salary