Job Description

The Administrative Nurse, LPN will support Clinical Review/Utilization Management processes in pre-service medical review, post-service medical review and concurrent review. The Administrative Nurse, LPN's clinical experience will allow these administrative tasks to be performed with a focus on member care. The Administrative Nurse, LPN must also perform tasks in accordance with NCQA UM Accreditation standards.

What You Will Be Doing

• Process authorization and medical review requests that are returned from the medical director (approvals and denials), including generation of denial letters and any verbal notification required (to members or providers); manage the peer to peer attachment and rescind process, including the generation of letters
• Request additional information necessary to process authorization and medical review requests (via phone, fax or letter); requested information will be based on Medical Coverage Guidelines and/or InterQual medical necessity criteria for the requested service(s)
• Benefit verification of requested services (especially SNF, LTAC and IP Rehab requests); determine participation status of providers; communicate with business partners such as Network for LOAs or Plan to Plan to assist in resolving issues
• Process authorization and medical review requests that do not have any clinical information submitted by the provider by summarizing for medical director review and processing decision (approval/denial), including generation of letters
• Census/Inventory Management, including (but not limited to), identification and resolution of duplicates, contacting provider offices to correct or update surgery dates, correcting authorization errors, etc.
• Create authorization requests
• Create referrals to case management, other party liability and care partners

What We Require

• 3+ years related work experience in Clinical, Managed Care, Home Health, Discharge Planning, Utilization Management
• High school diploma or GED
• LPN - Licensed Practical Nurse - State of Florida Licensure
• Excellent written and verbal communication skills ability to navigate multiple computer screens/systems ability to navigate/use Microsoft Office Applications
• Travel to our corporate or regional office may be required for meetings, collaboration, events and other work-related activities.

What We Prefer

• Experience in Jiva Knowledge of NCQA UM Accreditation requirements
• Experience reading and interpreting insurance benefits

General Physical Demand

• Exerting up to 10 pounds of force occasionally to move objects.
• Jobs are sedentary if traversing activities are required only occasionally.
• This position offers a hybrid work arrangement which combines flexibility with in office engagement.
• Team schedules are determined based on role requirements and business needs.

What We Offer

As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• Additional voluntary benefits available; and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Typical Hourly Pay Range: $25 - $32

Hourly Pay Range: $25 - $41

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.