Job Description

BTG, in partnership with a top ranked Health Insurance company in Florida, has an immediate need for a Medical Review Nurse to work in Largo, Florida.

Requirements of the Position:

Knowledge of medical terminology
Experience with prior authorization
Experience applying nationally recognized criteria, including InterQual
Knowledge of Medicare regulations and guidelines
Computer skills, including ability to use Microsoft Office suite
Previous experience within a call-center environment
Ability to navigate through multiple systems and screens to resolve authorization or medical review requests
Talking and typing simultaneously
Effective time management skills
Effective interpersonal and communication skills
Ability to use electronic medical record and claims systems
Problem solving abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team
Work respectfully and positively with others
Ability to manage multiple projects and prioritize work tasks to adhere to deadlines and identified time frames
Ability to think analytically and make decisions
Ability to manage large workload

Essential Functions
Perform medical record reviews to support improvement and compliance, abstract HEDIS data, to include over-read of reviews, working collaboratively with internal HEDIS STARs Team and the Quality Team.
Perform administrative functions to include; medical record request, faxing and calls to members and providers as needed. Maintain organized, updated reporting of activities with clear documentation. Required to track, monitor and report on the status of records and volume of work.
Complete claim research to identify the service performed, dates of service, provider type, and place of service. Research may include multiple systems and reports.
Must have previous medical record / quality review experience; HEDIS/STARS preferred
Must be proficient in Microsoft Office (Word, Excel, Outlook, and PowerPoint) as well as Internet research skills
Ability to communicate clearly verbally and in writing
Organizational skills are very important; must be able to work independently to complete tasks with minimal direction.
Review and authorize, as appropriate, phone/fax referral/authorization and clinical form requests per established criteria meeting compliance standards and time frames
Review all requests not approved by the non-clinical support rep to determine benefit coverage and medical necessity
Review cases and potential denials with the Medical Directors
Research requests not clearly meeting established criteria
Assist the Prior Authorization non-clinical reps with the Prior Authorization process
Coordinate and maintain complete written documentation on all prior authorization's requests.
Collaborate with other departments, such as Claims, UM, Quality, Disputes/Appeals, and other external vendors.
Log into phone queue to service providers
Answer inbound calls regarding authorizations within established time frame
Document contact information in electronic medical record system
Maintain productivity
Handle calls professionally
Provide accurate prior authorization information to provider offices

Benefits of the Position:

  • Full time hours
  • Medical / Dental / Vision
  • 401k
  • Preferred Qualifications:
    Disease management experience is helpful
    Recent experience in medical record reviews, data collection for HEDIS / Stars

    Required Experience:
    2+ years related work experience

    Required Education:
    High School Diploma or GED

    Required Licenses and Certifications
    LPN - Licensed Practical Nurse - State Licensure

    If you believe that your skills and experience are a match for this position, please submit your most current resume and a recruiter will be in contact. Resumes can also be submitted via email to ************* or by applying online at You may also give us a call at 904-998-9414 to speak to a recruiter.

    Application Instructions

    Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

    Apply Online