- Molina Healthcare (Tampa, FL)
- **Job Description** **Job Summary** The Medical Review Nurse provides support for medical claim and internal appeals review activities - ensuring ... clinical/ medical reviews of retrospective medical claim reviews, medical claims and...nursing experience, including at least 1 year of utilization review , medical claims review… more
- MyFlorida (Orlando, FL)
- REGISTERED NURSE Date: Dec 1, 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
- MyFlorida (Pembroke Pines, FL)
- OPS REGISTERED NURSE - 50509374 Date: Dec 10, 2025 The State Personnel System is an E-Verify employer. For more information click on our E-Verify Website ... . Requisition No: 866646 Agency: Veterans Affairs Working Title: OPS REGISTERED NURSE - 50509374 Pay Plan: Health Care Practice Position Number: 50509374 Salary:… more
- CVS Health (Tallahassee, FL)
- …As a QM Nurse Consultant you will be responsible for the review and evaluation of clinical information and documentation. + Reviews documentation and interprets ... medical records and system documentation to evaluate post-service claims for payment based on clinical policies, legislation, regulatory requirements, and… more
- Humana (Tallahassee, FL)
- …interpretation and independent determination of the appropriate courses of action. The Nurse Auditor 2 validates and interprets medical documentation to ensure ... caring community and help us put health first** The Nurse Auditor 2 performs clinical audit/validation processes to ensure...clinical and coding experience to conduct a clinical validation review of the inpatient medical record to… more
- Humana (Tallahassee, FL)
- …guidance where needed. Follows established guidelines/procedures. **KEY ACCOUNTABILITIES** + Review medical documentation, obtain additional information that may ... community and help us put health first** The Appeals Nurse 2 resolves clinical complaints and appeals. The Appeals...TRICARE, all HGB policies and procedures as well as medical necessity review criteria and privacy requirements… more
- Elevance Health (Tampa, FL)
- **Telephonic Nurse Case Manager II** **Location: This role enables associates to work virtually full-time, with the exception of required in-person training ... hours of receipt and meet the criteria._** The **Telephonic 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
- 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
- Zelis (FL)
- …Guidelines, AHA Coding Clinic and client specific coverage policies. Conduct prompt claim review to support internal inventory management to achieve greatest ... plan, and policy exclusions. Conduct reviews on inpatient DRG claims as they compare with medical records...concepts to expand the DRG product. + Manage assigned claims and claim report, adhering to client… more
- Molina Healthcare (Orlando, FL)
- …will work on set schedule) Looking for a RN with experience with appeals, claims review , and medical coding. JOB DESCRIPTION Job SummaryProvides support ... For this position we are seeking a (RN) Registered Nurse who must hold a compact license. This is...for clinical member services review assessment processes. Responsible for verifying that services are… more