Clinical Appeals Nurse - Health Plan

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 accurat...