Medicare Advantage Appeals RN

Responsibilities

• Conducts medical necessity and quality-of-care reviews for clinical appeals, grievances, and claim disputes.
• Affirms decisions align with Medicare Managed Care and CMS regulatory standards.
• Safeguards all cases to meet required state and federal timeframes.
• Supports departmental quality improvement efforts.
• Contributes to regulatory compliance and audit readiness.
• Collaborates with physicians, providers, vendors, and internal departments.
• Maintains accurate, fair, and timely determinations.
• Maintains thorough documentation and data integrity.

Requirements

• Minimum of 2 years of experience with clinical appeals within a health plan.
• Preferred experience with Medicare Advantage.
• Registered Nurse certification.
• Works in the BayCare Health System, Admin - Non Hospital Related-BHS location.
• Full-time, exempt position.
• Shift hours from 8:00 AM to 5:00 PM.
• Occasional weekend work.

Qualifications

• Hybrid schedule with 1 day required in office per week in Clearwater, Florida.