- Molina Healthcare (Miami, FL)
- …At least 2 years clinical nursing experience, including at least 1 year of utilization review , medical claims review , long-term services and supports ... DESCRIPTION **Job Summary** Provides support for medical claim and internal appeals review activities -...clinical/ medical reviews of retrospective medical claim reviews, medical claims and… more
- Humana (Tallahassee, FL)
- …in preparation of cases prior to review by the Humana G&A Medicare Medical Directors. The Nurse reviews the medical documentation, researching claims ... and Humana Medical Directors on submitted G&A cases. The G&A Nurse will participate in initiatives which result in improved member outcomes, operational… more
- MyFlorida (St. Augustine, FL)
- SENIOR REGISTERED NURSE SUPV - 50950032 Date: Jan 15, 2026 The State Personnel System is an E-Verify employer. For more information click on our E-Verify Website ... . Requisition No: 866953 Agency: Veterans Affairs Working Title: SENIOR REGISTERED NURSE SUPV - 50950032 Pay Plan: Career Service Position Number: 50950032 Salary:… more
- MyFlorida (Orlando, FL)
- REGISTERED NURSE Date: Dec 30, 2025 The State Personnel System is an E-Verify employer. For more information click on our E-Verify Website ... . Requisition No: 860343 Agency: Veterans Affairs Working Title: REGISTERED NURSE Pay Plan: Career Service Position Number: 50009834 Salary: $67,742.74 Posting… more
- Acute Home Healthcare (Orlando, FL)
- …Elements of Oasis Documentation + Medicare Programs (Home Health Value Based Purchasing, Pre- Claim Review ) + CMS and Other Regulatory Resources + Home Healthcare ... Job description An Acute Home Healthcare Nurse Educator serves as a role model, and...& Training Field Nurses (as needed) + Clinical Chart Review + QAPI: Quality Assurance / Performance Improvement Analysis… more
- Elevance Health (Lake Mary, FL)
- **Title** : ** Nurse Case Manager - Site of Care** **Location: Virtual - Ideal candidates would be willing to work East Coast Hours** **Virtual** : This role enables ... 9:00AM-5:00PM EST **Build the Possibilities. Make an Extraordinary Impact.** The ** Nurse Case Manager** is responsible for performing clinical and operational… more
- Elevance Health (Tampa, FL)
- ** Nurse Case Manager II** **Location** : This role enables associates to work virtually full-time, with the exception of required in-person training sessions, ... 48 hours of receipt and meet the criteria._** The ** Nurse Case Manager II** is responsible for care management...management plan and modifies as necessary. + Interfaces with Medical Directors and Physician Advisors on the development of… more
- Zelis (St. Petersburg, FL)
- …inquiries related to provider disputes. + Utilize the most up-to-date approved Zelis medical coding sources for claim review maintenance. + Communicate ... Medical Officer in managing disputes related to clinical claim reviews. This position is a production-based role with...+ Serve as subject matter expert for the Expert Claim Review Team on day-to-day activities including… more
- Sedgwick (Tallahassee, FL)
- …expertise and analytical skills to help evaluate medical -related components of claims . Completion of Legal Nurse Consultant certification or coursework is ... highly preferred.** **PRIMARY PURPOSE** **:** To handle complex or high exposure claim issues; to provide medical knowledge of the health care system and health… more
- Highmark Health (Tallahassee, FL)
- … review basis. Review process includes a review of medical documentation, itemized bills, and claims data to assure appropriate level of payment and ... rejection and the proper action to complete the retrospective claim review with the goal of proper...in Managed Care **LICENSES or CERTIFICATIONS** **Required** + Registered Nurse **Preferred** + Certified Medical Coder or… more
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