CMS and NCQA Utilization Management, RN - Florida Remote

Job Summary:
We are seeking a highly skilled and experienced Registered Nurse (RN) to join our team as a Utilization Management Compliance Specialist. As a Specialist, you will apply your discipline-specific knowledge and skills in utilization management, compliance, and quality reporting to support the Company's operations and ensure adherence to Centers for Medicare and Medicaid Services (CMS) and National Quality Care Assessment (NQCA) guidelines.

Essential Functions:

• The essential functions listed represent the major duties of this role, additional duties may be assigned.  
• Serve as a liaison between internal clients and functional departments; help clients achieve their objectives by serving as a resource in the interpretation, application and compliance with internal and external laws, regulations, policies, procedures, standards and practices.  
• Identify risks, evaluate controls and prepare findings and recommendations. Implement compliance programs to prevent illegal, unethical or improper business practices.
• Ensure through audits that the organization’s programs are consistently administered in compliance with organizational policies and procedures, contractual obligations, rulings, laws and government regulations. 
• Monitor and evaluate the effectiveness of solutions, policies, practices and processes to ensure continuous improvement, good client relations and adherence to business requirements. Recommend improvements to achieve and deliver high quality, value-added services.  
• Develop, implement, administer and revise policies, procedures and programs that meet business needs; assist and/or lead program development and enhancements.  
• Research, analyze, maintain, modify, validate and prepare data, information and content used in making business decisions. Present findings and articulate results.  
• Produce, edit and distribute a variety of business documents such as reports, proposals, policies, procedures, audit results, issue papers, marketing materials, newsletters, brochures, etc.  
• Create, present and/or facilitate meetings, webinars, conference calls, training programs, education sessions, certifications, etc. for a variety of internal and external audiences. 
• Represent assigned function at external hearings, mediations, audits, meetings, etc.  
• Participate on or lead large, complex departmental and/or divisional projects. Plan, organize, monitor and control projects to ensure the effective use of resources and adherence to project management standards and reporting requirements. 
• Participate on Company workgroups and initiatives.  
• Develop and build internal and external partnerships to improve communication, coordination, collaboration and effective working relationships within own department, across the Company and outside of the Company. 
• Mentor and coach less experienced coworkers on the technical and interpersonal skills needed for effective job performance.  

Required Experience:
5+ years related work experience. 
Related Bachelor’s degree or additional related equivalent work experience 

FL active and unrestricted RN license or compact RN license 
 

General Physical Demands:
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally. 

What We Offer: 
As a Florida Blue employee, you will be at the heart of GuideWell’s vision – to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living. 

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to: 
 

• Medical, dental, vision, life and global travel health insurance;
• Income protection benefits: life insurance, 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 and 2 well-being days;
• Additional voluntary benefits available; and
• A comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases. 

Annualized Salary Range: $77,600 - $126,100

Typical Annualized Hiring Range: $77,600 - $97,000

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.