Clinical Appeals Nurse - Health Plan - 159292

Clinical Appeals Nurse - Health Plan

Clearwater: Park Place | Business and Administrative | Full Time

At BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that's built on a foundation of trust, dignity, respect, responsibility and clinical excellence.

Description

Conducts medical necessity and quality-of-care reviews for clinical appeals, grievances, and claim disputes to ensure decisions align with Medicare Managed Care and CMS (Centers for Medicare & Medicaid Services) regulatory standards.

Ensures that all cases meet required state and federal timeframes, supports departmental quality improvement efforts, and contributes to regulatory compliance and audit readiness.

Collaborates with physicians, providers, vendors, and internal departments to ensure accurate, fair, and timely determinations while maintaining thorough documentation and data integrity.

Minimum Qualifications

• 2 years of experience with case management and/or clinical appeals or claims.
• Registered Nurse

Location: Park Place

Status: Full Time, Exempt: Yes

Shift Hours: 8:00 AM - 5:00 PM

Weekend Work: Occasional

On Call: No

How often will this team member be working remotely? Hybrid - 1 day required in office per week - Clearwater, Florida

Equal Opportunity Employer Veterans/Disabled