• Clinical Appeals Nurse - Health Plan

    BayCare Health System (Clearwater, FL)


    Why BayCare?

     

    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.

    Summary:

    + Conducts clinical reviews needed to resolve and process clinical appeals and claims.

    + Assists with the intake/notification process of cases in the department.

    + Provides monitoring of cases involving medical decisions and quality of care and service.

    + Ensures all cases are completed in accordance with State and Federal regulatory requirements for timelines.

    + Ensures integrity of departmental database by recoding in a thorough, timely and accurate entry assigned cases.

    + Assists with analyzing and reporting of cases through the Quality Committee.

    + Reviews medical records, conducts research on standards of practice, regulations and policy/procedures relevant to cases under review and assesses clinical data to investigate and resolve disputes over the medical necessity of services, approvals, pre-certifications and other cases.

    + Prepare and complete written summaries of documentation required for further medical review, hearings and appeal processes of clinical cases.

    + Participates in departmental meetings, trainings and audits as required. Knowledge of medicare, managed care industry and health care processes.

    + Knowledge of clinical review processes including how to analyze and research clinical issues and the appeals and grievance processes.

    Minimum Qualifications:

    + 2 years of experience with case management and/or clinical appeals or claims.

    + Registered Nurse

    **Facility:** BayCare Health System, Admin - Non Hospital Related-BHS

     

    Status:** **Full Time, Exempt: Yes

     

    Shift Hours:** **8 hour shift, days

     

    Weekend Work:** **Occasional

    On Call:** **No

    **How often will this team member be working remotely?** Hybrid

    Equal Opportunity Employer Veterans/Disabled

    **Position** Clinical Appeals Nurse - Health Plan

    **Location** Clearwater:Park Place | Business and Administrative | Full Time

    **Req ID** 129655