Administrative Nurse Lpn-- Remote

Get to know us!
Florida Blue, a GuideWell Company, has been providing insurance to residents of Florida for 75 years. Driven by its mission of helping people and communities achieve better health, the company serves more than five million healthcare members across the state. We are looking for exceptional people who will bring our mission to life and succeed by putting the member first.

Important information:
This position is required to work Monday thru Friday 9:30am until 6:00pm
Can work remotely

What you will do:
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.
The essential functions listed represent the major duties of this role, additional duties may be assigned.
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 you will need
3+ years related work experience in Clinical, Managed Care, Home Health, Discharge Planning, and/or Utilization Management
Excellent written and verbal communication skills
Experience with navigating multiple computer screens/systems
Experience with Microsoft Office
LPN - Licensed Practical Nurse - State Licensure

What we Preferred you to have:
Experience in Jiva
Knowledge of NCQA UM Accreditation requirements
Experience reading and interpreting insurance benefits

General Physical Demands:
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
Physical/Environmental Activities: Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally
What We Offer:
As a Florida Blue employee, you will thrive in our Be Well, Work Well, GuideWell culture where being well as an individual, and working well as a team, are both important in serving our members and communities.

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.

Hourly Pay Range: $24 - $39
Typical Hourly Pay Range: $24 - $30

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 Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive, and equitable culture for our employees and communities.