Job Description

BTG, in partnership with a top ranked healthcare company in Florida, has an immediate need for a Technical Support/Help Desk professional.

The Medical Review Nurse LPN reviews, authorizes, coordinates, and responds to requests for services for client members. This position also communicates telephonically with providers and their offices, and occasionally with members. Makes decisions based on established policies and procedures, the client's medical coverage guidelines, benefits, InterQual criteria, nursing knowledge. Refers cases to the client's medical directors for potential denial.

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

Requirements of the Position:

  • 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 the company 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

    Job Requirements
    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

    Preferred:
    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
  • Full time hours
  • Medical / Dental / Vision
  • 401k

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 https://jobs.btginc.com. 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!

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