- CVS Health (Tallahassee, FL)
- …benefit plan structure and regulatory requirements are required to support the appeals review . -Pro-actively and consistently applies the regulatory and ... Must reside in Florida Responsible for intake, investigation and resolution of appeals , complaints and grievances scenarios for all products, which may contain… more
- Molina Healthcare (Tampa, FL)
- …will work on set schedule) Looking for a RN with experience with appeals , claims review , and medical coding. **Job Summary** Utilizing clinical knowledge ... and experience, responsible for review of documentation to ensure medical necessity...state/federal regulations **REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:** Active, unrestricted State Registered Nursing ( RN ) license in good standing.… more
- Molina Healthcare (Tampa, FL)
- …outcomes within compliance standards. **KNOWLEDGE/SKILLS/ABILITIES** + The Clinical Appeals Nurse ( RN ) performs clinical/ medical reviews of previously ... + Serves as a clinical resource for Utilization Management, Chief Medical Officer, Physicians, and Member/Provider Inquiries/ Appeals . + Provides training,… more
- Elevance Health (Tampa, FL)
- ** Nurse Appeals ** **Hybrid 1:** This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing ... an accommodation is granted as required by law._ The ** Nurse Appeals ** is responsible for investigating and...+ Extrapolates and summarizes medical information for medical director, consultants and other external review .… more
- Healthfirst (FL)
- …productivity and quality for each Specialist against expectations + Prepare cases for Medical Director Review ensuring that all pertinent information (ie case ... + Bachelors degree + Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization… more
- Intermountain Health (Tallahassee, FL)
- …on clinical Appeals and Audits for Intermountain Health. The Audit/ Appeals RN Consultant will execute clinical audits of medical records on behalf of ... **Job Description:** The RCO Audit & Appeals RN Consultant is responsible for...stakeholders throughout the denial process up to and including medical review boards and in the court… more
- Monte Nido (Miami, FL)
- …potential denials, and potential for private payment. + Follow workflow and medical record requirements for utilization review and clinical documentation across ... the opportunity for people to realize their healthy selves. **Utilization Review Clinician** **Monte Nido** **Remote** **Monte Nido has been delivering treatment… more
- Public Consulting Group (Tallahassee, FL)
- …concurrent and retrospective reviews + Use clinical documentation and clinical review criteria to make determinations regarding qualifying health care costs + ... Accurately records all review determinations and supporting documentation + Contacts providers and...escalates the issues appropriately + Understand and facilitate the Appeals and Grievances process + Assists members with the… more
- Prime Therapeutics (Tallahassee, FL)
- …Patient Programs. **Minimum Qualifications** + Associates - Nursing + Bachelors - Nursing + RN - Registered Nurse , State and/or Compact State Licensure - ... and spreadsheets. + Supports clinical services such as the appeals program. + Participates in meetings and consults with...for work visa or residency sponsorship **Additional Qualifications** + Registered Nurse ( RN ). + 5… more