Acute Care, Centers for Medicare and Medicaid Services (CMS), Clinical Validation, Data Quality, Documentation, Health Plan, Healthcare, Healthcare Quality, Home Care, Hospital, Long-Term Care, Managed Care, Medicare, On Call, Outpatient Care, Philosophy, Quality Management, Quality of Care, Registered Nurse (RN), Regulations, Regulatory Compliance, Time Management
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 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.
- Ensures that all cases meet required state and federal timeframes, supports departmental quality improvement efforts, and contributes to regulatory compliance and audit readiness.
- Collaborates with physicians, providers, vendors, and internal departments to ensure accurate, fair, and timely determinations while maintaining thorough documentation and data integrity.
Minimum Qualifications:
- 2 years of experience with clinical appeals within a health plan, Medicare Advantage experience highly preferred
- Registered Nurse
Facility: BayCare Health System, Admin - Non Hospital Related-BHS
Location: Park PlaceStatus: Full Time, Exempt: YesShift Hours: Thursday - Monday. 8:00 AM - 5:00 PM
Weekend Work: Every
On Call: No
How often will this team member be working remotely? Always
Equal Opportunity Employer Veterans/Disabled