Job Description

One of our clients in the Southside area of Jacksonville, FL has an immediate need for a Pre Serv Med Rev Nurse LPN . The perfect candidate will have the following skills and experience:
  • Apply medical knowledge and expertise in reviewing claims, authorization requests, and subscriber/ provider inquiries 
  • Render medical decisions on pre-service requests and post-service claims per established criteria, meeting compliance standards and timeframes 
  • Identifies questionable medical practices, existence of medical necessity, and extent of benefit coverage 
  • Document findings and render medical decision in various Florida Blue systems 
  • Manage medical review inventory, to include resolving workflow problems and identifying continuous improvement opportunities 
  • Identify formal education opportunities and needs for providers and their staff and communicate these needs to appropriate departments 
  • Consult with Medical Director and other resources on issues related to claims, member and provider inquiries /reviews 
  • Conducts telephonic reviews with ability to cover phones between 8am and 6pm daily.
  • Follow regulatory requirements 
  • Project work as needed 
  • Moderate to heavy keying required 
  • Current, active, unrestricted Florida LPN license 
  • High School Diploma or equivalent GED 
  • 2+ years of clinical nursing experience as an LPN 
  • Previous Medicare or Managed Care experience, including medical review, prior authorization or appeals, with experience utilizing established criteria to make medical review determinations 
  • Experience working with one or more of the following coding systems: ICD-9, ICD-10, CPT-4 and HCPC coding 
  • Excellent written and verbal communication skills 
  • Experience working with multiple research/processing systems 
  • Experience working with MS Word, Excel and PowerPoint 
Business Specific Criteria (preferred skills): 
  • Associate’s degree 
  • Experience with utilization management systems or clinical decision making tools such as Medical Coverage Guidelines (MCG) or InterQual 
  • Experience working with BCBSF systems such as: JIVA, Diamond, Quest, and Siebel 
  • Experience with Medicare review using CMS guidelines (e.g. NCD, LCD, and IOM’s) 
  • Ability to navigate through multiple systems and screens to resolve authorization or medical review requests 
  • Effective time management skills 
  • Work cooperatively, positively, and collaboratively in an interdisciplinary team 
  • 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 
  • Call Center Experience
If you believe that your skills and experience are a match for this position, please e-mail your resume to, or apply on line at (search jobs). 

Application Instructions

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