Licensed Practical Nurse (LPN) - Administrative Nurse

Florida Blue is seeking a Licensed Practical Nurse (LPN) to serve as an Administrative Nurse supporting Clinical Review, Utilization Management, and medical review processes. In this role, you will apply your clinical background to administrative tasks with a focus on member care while ensuring compliance with NCQA UM Accreditation standards.

Responsibilities

• Process authorization and medical review requests returned from the medical director, including generation of denial letters and verbal notifications to members or providers
• Manage peer-to-peer attachments and rescind processes, including letter generation
• Request additional clinical information necessary to process authorization and medical review requests via phone, fax, or letter, based on Medical Coverage Guidelines and InterQual medical necessity criteria
• Perform benefit verification for requested services, particularly SNF, LTAC, and inpatient rehabilitation requests; determine provider participation status
• Communicate with business partners such as Network for Letters of Authorization or Plan-to-Plan arrangements to resolve issues
• Process authorization and medical review requests lacking clinical information by summarizing for medical director review and decision
• Manage census and inventory, including identification and resolution of duplicates, contacting provider offices to correct or update surgery dates, and correcting authorization errors
• Create authorization requests and referrals to case management, other party liability, and care partners

Required Qualifications

• 3 or more years of related work experience in Clinical, Managed Care, Home Health, Discharge Planning, or Utilization Management
• High school diploma or GED
• Licensed Practical Nurse (LPN) license issued by the State of Florida
• Excellent written and verbal communication skills
• Ability to navigate multiple computer screens and systems
• Proficiency with Microsoft Office Applications

Preferred Qualifications

• Experience with Jiva
• Knowledge of NCQA UM Accreditation requirements
• Experience reading and interpreting insurance benefits

Physical Requirements

• Exerting up to 10 pounds of force occasionally to move objects
• This position is sedentary with only occasional traversing activities

Work Arrangement

• Hybrid work arrangement combining flexibility with in-office engagement
• Team schedules determined based on role requirements and business needs
• Travel to corporate or regional office may be required for meetings, collaboration, events, and other work-related activities

Compensation and Benefits

• Hourly pay range: $25 to $41 (final pay determined based on market competitiveness, internal equity, and job-related knowledge, skills, training, and experience)
• Medical, dental, vision, life, and global travel health insurance
• Life insurance, short-term and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan with employer match
• Paid time off, volunteer time off, 10 holidays, and 2 well-being days
• Additional voluntary benefits and comprehensive wellness program
• Opportunities for incentive or commission compensation
• Regular annual reviews with pay-for-performance considerations for base pay increases

Note: Benefits may vary based on the state in which work is performed. Benefits for part-time and seasonal employees may differ.