Job Description

One of our clients on the Southside area of Jacksonville, FL has an immediate need for a Pre/Post Service Medical Review Nurse RN. The perfect candidate will have the following skills and experience:

Pre/Post Service Medical Review Nurse - LPN
  • 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 client 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

Job Requirements:
  • 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). 
If you have any questions, please call 904-998-9414 and reference Medical Review Nurse position.

Application Instructions

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