Clinical Appeals Nurse - Health Plan
About The Position
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 clinical reviews needed to resolve and process clinical appeals and claims. Assists with the intake/notification process of cases in the department. Provides monitoring of cases involving medical decisions and quality of care and service. Ensures all cases are completed in accordance with State and Federal regulatory requirements for timelines. Ensures integrity of departmental database by recoding in a thorough, timely and accurate entry assigned cases. Assists with analyzing and reporting of cases through the Quality Committee. Reviews medical records, conducts research on standards of practice, regulations and policy/procedures relevant to cases under review and assesses clinical data to investigate and resolve disputes over the medical necessity of services, approvals, pre-certifications and other cases. Prepare and complete written summaries of documentation required for further medical review, hearings and appeal processes of clinical cases. Participates in departmental meetings, trainings and audits as required. Knowledge of medicare, managed care industry and health care processes. Knowledge of clinical review processes including how to analyze and research clinical issues and the appeals and grievance processes.
Requirements
- 2 years of experience with case management and/or clinical appeals or claims.
- Registered Nurse
Responsibilities
- Conducts clinical reviews needed to resolve and process clinical appeals and claims.
- Assists with the intake/notification process of cases in the department.
- Provides monitoring of cases involving medical decisions and quality of care and service.
- Ensures all cases are completed in accordance with State and Federal regulatory requirements for timelines.
- Ensures integrity of departmental database by recoding in a thorough, timely and accurate entry assigned cases.
- Assists with analyzing and reporting of cases through the Quality Committee.
- Reviews medical records, conducts research on standards of practice, regulations and policy/procedures relevant to cases under review and assesses clinical data to investigate and resolve disputes over the medical necessity of services, approvals, pre-certifications and other cases.
- Prepare and complete written summaries of documentation required for further medical review, hearings and appeal processes of clinical cases.
- Participates in departmental meetings, trainings and audits as required.
- Knowledge of medicare, managed care industry and health care processes.
- Knowledge of clinical review processes including how to analyze and research clinical issues and the appeals and grievance processes.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
Number of Employees
5,001-10,000 employees
