Pre-Service Medical Review Nurse, RN

GuideWell Source

. Serve as Florida Blue Medicare's clinical expert for providers, facilities and subscribers .

Posted 10/14/2026full-timeFlorida • United StatesJuniorMid-Level💰 $71,200 - $115,700 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Case Management, with a strong focus on Benefit Administration and Quality Care Coordination. Proficient in ICD-9 Coding and possesses a solid understanding of Medicare Advantage and Managed Care processes.

Highest-signal resume keywords

Utilization Management ExperienceRegistered Nurse LicensureICD-9 CodingManaged Care ExperienceExcellent Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization ManagementCase ManagementBenefit AdministrationClinical ReviewMedical Necessity AuthorizationPre-Service Medical ReviewConflict ResolutionDetail-OrientedDecision-MakingPlanning and Organizational Skills

Soft Skills

Excellent Verbal CommunicationExcellent Written CommunicationSelf-StarterAbility to Work IndependentlyFlexibility

Tools & Technologies

InterQualBasic PC Knowledge

Certifications & Qualifications

Registered Nurse LicenseFlorida License

Industry Keywords

Medicare AdvantageManaged CareRegulatory AgenciesHome HealthClinical Work

About the role

Key responsibilities & impact

Serve as Florida Blue Medicare's clinical expert for providers, facilities and subscribers
Oversee subscriber well-being while ensuring proper benefit administration, cost effectiveness and coordination of quality care
Review and resolve complex processing issues and utilization management cases
Review and authorize phone/fax referrals, authorizations and clinical form requests for benefit coverage and medical necessity
Process pre-service Medical Review requests accurately and timely according to internal policies and procedures
Research requests that do not clearly meet established criteria
Review subscriber medical information for appropriate benefit administration
Abstract clinical cases and review cases and potential denials with Medical Directors
Coordinate and maintain complete written documentation for prior authorization requests
Provide telephone customer service to members and providers by answering benefit questions and resolving issues
Conduct training for new staff members and providers as needed

Requirements

What you’ll need

2+ years related work experience, including combined experience in utilization management, case management, home health and clinical work
1 year utilization management experience
RN — Registered Nurse — State Licensure and/or Compact State Licensure; Florida license, unrestricted
ICD-9 coding
Excellent planning and organizational skills
Excellent verbal and written communication skills
Self-starter
Ability to work independently
Conflict resolution skills
Detail-oriented
Ability to handle multiple tasks
Decision-making skills
Flexibility
Basic PC knowledge preferred
Managed care experience, including InterQual, preferred
Understanding of regulatory agencies preferred
Medicare Advantage experience preferred

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Income protection benefits, including life insurance and short- and long-term disability programs
Leave programs to support personal circumstances
Retirement Savings Plan including employer match
Paid time off
Volunteer time off
10 holidays
2 well-being days
Additional voluntary benefits
Comprehensive wellness program
Opportunities for incentive or commission compensation
Annual reviews with pay-for-performance considerations for base pay increases
Hybrid work arrangement combining flexibility with in-office engagement