Job Description

Medical Review Nurse

The range for this role is $73,000 - $99,500. Actual base pay will be determined based on a successful candidate's work location, skills/abilities, experience, and education. This role includes opportunity to receive an annual bonus target of 5% of annual eligible earnings. Actual bonus amounts are determined by length of time in role, individual performance, and organizational performance.

Interested applicants must be willing and able to work onsite minimum 4 times per week in either our Melbourne, FL or Orlando, FL office.

The Job

The Medical Review Nurse (Senior Clinical Reviewer) works to summarize and correlate concise, accurate information on medical reviews to determine eligibility of medical bills per the program guidelines. In this role, 70% of the time is spent performing pre-service and post-service medical reviews and/or reviews for high dollar, complex medical cases and collaborating with other departments to optimize cost savings. This position will be expected to make independent decisions regarding timing and omission of medical reviews in deference to other department processes based on the dollar amount of the bill and the Ministry's cost strategy.

Essential Job Duties & Responsibilities

• Organize and review medical records, lab results, radiology, and pathology reports for conditions ineligible for sharing (CIF's)
• Determine eligibility of members' medical bills and/or upcoming procedures/treatments according to the program guidelines
• Collaborate with other departments to maximize cost savings for individual cases and optimal outcomes for the members
• Appropriately apply the program guidelines to the individual cases reviewed
• Work autonomously to prioritize and manage workload
• Document effectively in appropriate systems
• Comply with all organizational HIPAA requirements
• Contribute to the exercise and expression of the Ministry's Christian beliefs
• All other duties as assigned

Essential Skills & Abilities

• Understanding of medical bill processing and provider bill negotiation
• Understand diversity of systems and work flows as they relate to the type of review or assignment
• Able to multitask in multiple operating systems
• Able to work for extended periods of time on the computer
• Proficiency at interpreting medical records and writing detailed reports and conclusions
• Strategic understanding of negotiations, third party processes, bill validation, and care management to determine when to utilize/defer to these processes for active review cases
• Ability to be objective and impartial and conclude a case
• Ability to communicate effectively with both internal and external customers
• Practice good interpersonal skills and work as a member of a team
• Possess the ability to adapt to changing processes
• Working knowledge and application of program guidelines
• Understanding of systems and work flows as they relate to the type of review or assignment
• Ability to utilize the internet including e-mail and search engines
• Word processing skills of at least 25 wpm
• Basic knowledge in Microsoft Office (Excel, Word, Outlook) and ability to use a database system
• Knowledge of document imaging system

Core Competencies/Demonstrable Behaviors

• Collaborates builds partnerships and works collaboratively with others to meet objectives. This role requires strong interdepartmental understanding and communication.
• Thoroughness ensures information is complete, accurate; remediates errors when identified and applies feedback to avoid future mistakes.
• Innovation able to develop and introduce new, improved methods for completing assignments
• Managing Change demonstrates support for departmental improvements with positive attitude
• Forward Thinking the ability to anticipate the implications and consequences of situations and take appropriate action to be prepared for possible contingencies

Education and/or Experience

• RN license with sound knowledge of anatomy and physiology and disease processes required
• 1-3 years' experience in medical reviews required
• 2-3 years of clinical experience strongly preferred
• Experience with Utilization Review or Case Management preferred

Supervisory Responsibilities

• This job has no supervisory responsibilities

Incentives & Benefits

We work hard to serve our Medi-Share Members, but know we can only do that if we invest in our employees professionally, financially, physically, socially, and spiritually. We purposefully invest in our employees so that our employees can invest in others.

For full-time employees working 30 hours or more, some of our benefits include, but are not limited to:

• 100% paid Medical for employees/99% for family
• Generous employer Health Savings Account (HSA) contributions
• Employer-paid Life Insurance (3x salary) and Long-term Disability Insurance
• 6 weeks of paid parental leave (for both mom and dad)
• Dental - two plans to choose from
• Vision
• Short-term Disability
• Accident, Critical Illness, Hospital Indemnity
• 401(k) up to 4% match on ROTH or Traditional contributions
• Generous paid-time off and 11 paid holidays
• Wellness plan including Financial, Occupational, Mental/Spiritual, and Physical health incentives up to $50/mo
• Employee Assistance Program including no cost, in-person mental health visits and employee discounts
• Monetary Anniversary Awards Program
• Monetary Birthday Awards

Minimum Age Requirement: Due to the nature of the responsibilities associated with this positionincluding independent decision-making, access to confidential information, and potential exposure to regulated environmentscandidates must be at least 18 years of age at the time of hire. This requirement is in accordance with applicable federal and state labor laws and is intended to ensure compliance with workplace safety and legal standards.

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