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:
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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.
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Ensures that all cases meet required state and federal timeframes, supports departmental quality improvement efforts, and contributes to regulatory compliance and audit readiness.
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Collaborates with physicians, providers, vendors, and internal departments to ensure accurate, fair, and timely determinations while maintaining thorough documentation and data integrity.
Minimum Qualifications:
Facility : BayCare Health System, Admin - Non Hospital Related-BHS
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
Position Clinical Appeals Nurse - Health Plan
Location Clearwater:Park Place | Business and Administrative | Full Time
Req ID 159292
