Clinical Appeals Nurse - Health Plan

Why Bay Care? At Bay Care, 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.

• 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 regulatory standards.
• Ensures that all cases meet required state and federal time frames, 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.

• 2 years of experience with case management and/or clinical appeals or claims within a health plan, Medicare Advantage experience highly preferred
• Registered Nurse

Bay Care Health System, Admin - Non Hospital Related-BHS

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