Florida Licensed Medical Review Nurse

Job Summary

Utilizing clinical expertise, the full-time Florida Licensed Medical Review Nurse will conduct reviews of medical documentation to ensure medical necessity and appropriate levels of care, supporting appeals for denied prior authorizations while working day shift hours aligned with Eastern Standard Time (EST) and maintaining flexibility for weekend and holiday coverage.

Key responsibilities

• Facilitates medical review of prospective, retrospective, and concurrent appeals for denied prior authorizations
• Reevaluates medical claims and associated records to assess appropriateness of services and ensure accurate billing
• Serves as a clinical resource for utilization management and provides training and support to clinical peers

Required qualifications

• At least 2 years of clinical nursing experience, including 1 year in utilization review or medical claims review
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Knowledge of ICD-10, CPT coding, and HCPCS
• Experience working within state, federal, and third-party regulations
• Analytic and decision-making skills, along with organizational abilities