Medicare Advantage Appeals RN

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: 8:00a - 5:00p, Monday - Friday

Weekend Work: Every 5th weekend on call

On Call: Yes - Every 5th weekend

How often will this team member be working remotely? Hybrid - occasional in office meetings and residency

Equal Opportunity Employer Veterans/Disabled