GuideWell and its family of forward-thinking enterprises are at the forefront of the healthcare industry’s transformation, with a mission to improve the health of individuals and communities. We enable members to optimize their health and attain their health care objectives as a highly integrated care team by providing access to affordable, high-quality health solutions.
Since 1975, Florida Blue, a GuideWell company, has offered health insurance to Florida residents. Established to enhance the health of individuals and communities, the organization provides services to over five million healthcare members throughout the state. We are searching for exceptional individuals who will accomplish our mission by placing them first.
What is your impact?
The Medical Review Nurse collaborates with facilities, providers, and subscribers to ensure the appropriate management of benefits, cost-effectiveness, and coordination of the provision of high-quality care, all while monitoring the subscribers’ well-being.
What are your key responsibilities?
- Utilize medical expertise and knowledge to evaluate claims and member/provider inquiries.
- Analyze post-service medical claims by predetermined criteria, ensuring adherence to compliance standards and time constraints.
- Determines whether medical procedures are dubious, whether medical necessity exists, and the scope of benefit coverage.
- Record discoveries in multiple Florida Blue systems
- Manage the inventory of medical reviews, including identifying opportunities for continuous improvement and resolving workflow issues.
- Determine the formal education requirements and opportunities for providers and their personnel, and convey these requirements to the relevant departments.
- Consult the Medical Director and other pertinent resources regarding claims, member, and provider reviews and inquiries.
What is required?
- Unrestricted, active, and current Florida RN license
- RN with at least two years of clinical nursing experience
- Prior experience with Medicare or managed care, including medical review or appeals, and the ability to make medical review determinations using established criteria
- Proficiency in operating the ICD-10, CPT-4, and HCPC codes
- Working knowledge of multiple research and processing systems
- Proficiency in operating Microsoft Word, Outlook, Excel, and PowerPoint
What is preferred?
- BSN (Bachelor of Science in Nursing) certification
- Proficiency in utilizing clinical decision-making tools and utilization management systems, including but not limited to Medical Coverage Guidelines (MCG), CMS guidelines, and InterQual
- Work experience with Florida Blue systems, including but not limited to JIVA, Diamond, Quest, Convergence, and Siebel
- Proficient in navigating through numerous systems and displays to address requests for authorization or medical review
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Benefits of Nurse RN Jobs in USA:
- Maintaining Job Stability: Consistently high demand exists for registered nurses, and the nursing profession is frequently regarded as resistant to economic downturns. This indicates that, relative to other professions, RNs generally enjoy job security and a reduced likelihood of experiencing unemployment.
- Comparative Wages: In general, RNs are compensated competitively. Although compensation may differ depending on experience, location, and area of specialization, nursing is generally a well-compensated field.
- Diverse Opportunities for Employment: Nursing encompasses a diverse array of professional environments, including but not limited to hospitals, clinics, nursing homes, and educational institutions. Additionally, RNs have the option to specialize in pediatrics, oncology, critical care, and other fields.
- Adaptability: flexibility: A variety of RN positions, including part-time, full-time, and per diem positions, provide flexible work hours. Individuals who wish to reconcile work with other obligations may find this flexibility useful.
- Satisfaction at Work: As a rewarding profession, nursing enables RNs to positively influence the lives of their patients. Providing assistance and compassion to others during challenging circumstances can elicit profound emotional satisfaction.
- Promising advancement prospects: By obtaining additional credentials and continuing their education, RNs can advance their careers. They may pursue careers as nurse educators, nurse practitioners, nurse anesthetists, or nurse administrators and directors, among other leadership positions.
- An individual’s sense of satisfaction: Nurses are afforded the chance to develop profound connections with patients and their families. Providing emotional support and cultivating relationships can be gratifying on an individual level.
- Health Advantages: A considerable number of healthcare organizations offer comprehensive health and wellness benefits to their staff, encompassing vision, dental, and medical coverage.
- Education Continuation: A profession that promotes lifelong learning is nursing. A significant number of employers offer and encourage opportunities for continuous professional development and education.
- Travel Possibilities: As travel nurses, certain registered nurses are allowed to work in various locations, acquire a wide range of experiences, and take advantage of travel benefits.
- Diverse Workplace Environments: Education, correctional facilities, and busy urban hospitals are just a few of the contexts in which registered nurses may be employed. This diversity can add excitement and interest to the task.
- The Influence on the Community: The contribution of nurses to the health and well-being of their communities is crucial. They consistently make contributions to community outreach programs and public health initiatives.
- Engaging in networking: There are numerous opportunities to network with other healthcare professionals in the nursing profession, which can be advantageous for professional development and advancement.
- Compassionate Resilience: The field of nursing demands that individuals possess emotional resilience and the capacity to adjust to difficult circumstances, both of which contribute to personal development and the development of coping mechanisms.
General Physical Demands
The occasional exertion of 10 pounds of force to move objects constitutes sedentary labor. Occasional traversal activities qualify as sedentary occupations.
What We Offer:
You will flourish as an employee of Florida Blue within our Be Well, Work Well, GuideWell culture, which places equal value on teamwork and personal health in the service of our communities and members.
- To promote and enhance one’s overall welfare, extensive benefits are provided. You will have access to the following as an employee: medical, dental, vision, life, and international travel health insurance;
- Life insurance, short-term and long-term disability programs, and leave programs to assist with personal circumstances are examples of income protection benefits.
- The employer makes contributions to retirement savings plans and matching contributions.
- Eleven holidays, volunteer time off, and paid time off
- Further voluntary benefits are offered, and
- An all-encompassing wellness regimen
The design of employee benefits complies with state and federal employment regulations. By the state in which the activity is executed, benefits may differ. Seasonal, intern, and part-time employees may be eligible for distinct benefits.
To promote your financial security, we provide competitive wages in addition to potential incentive or commission-based compensation. In addition, we conduct annual evaluations that incorporate pay-for-performance factors to determine base pay increases.
- Range of annual salaries: $66,400 to $107,900
Typical Annualized Hiring Range: $66,400 – $83,000
In determining your final compensation, market competitiveness, internal equity, and job-related knowledge, skills, training, and experience will all be taken into account.
For More Info:
Email Your CV, and We’ll Find the Best Pathway For you: info@awakeuk.com
Frequently Asked Questions:
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How can I get a job as a nurse in the USA?
Once you have your Registered Nurse license, you can look for a job through a nursing recruitment agency or US-based employer. When you have received a job offer, you can apply for a US visa. The last step is to apply for a nonimmigrant visa that will allow you to work in the US.
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Can I work in the USA without Nclex?
Is NCLEX mandatory to work as a foreign nurse? While the NCLEX exam is not technically required to work as a nurse in the United States, employers typically require it.
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Are nurses in demand in the USA?
While the average growth rate for all occupations is 5%, the job outlook for nursing is 6% between 2021 and 2031. Each year, through 2031, will see approximately 203,000 jobs for RNs. Increasing the nurse workforce is necessary throughout the US.
