Denials Specialist RN - Utilization Review

Baycare; Tampa (FL); Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

Health, Dental, Vision

Paid time off

Tuition reimbursement

401k match

Performance bonuses

Community discounts

Job summary

BayCare is seeking a Denials Specialist-Utilization Review in the Tampa area. The role focuses on timely reviews of payor and facility claims that have been denied or do not meet medical necessity, with collaboration across Physician Advisors, Registration, CBO, CAU, and Coding teams.

Responsibilities include maintaining an efficient appeal process, correcting billing statuses, and identifying trends in adverse determinations to inform stakeholders. The position is hybrid in Tampa/St.

Qualifications

• RN license required.
• Masters degree in nursing preferred.
• 2 years Utilization Review or Care Coordination/Case Management/Managed Care/Finance experience required.
• Preferred Medicaid/Medicare experience.
• Preferred Accredited Case Manager Certification or Certified Case Manager.

Responsibilities

• Timely reviews of payor, inpatient and outpatient claims that are denied or may not meet medical necessity.
• Coordinate with Physician Advisors, Registration, Central Business Office, Central Authorization Unit, and Coding department.
• Maintain and coordinate a timely appeal process or correct billing status as needed.
• Identify trends in adverse determinations and share findings with stakeholders.

Education

RN License

Masters Degree in Nursing

Accredited Case Manager Certification

Certified Case Manager

Job description

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Category Clinical

Clinical

Work Type Press down arrow to select

Full Time

Job Code Minimum Salary

Minimum Salary

Maximum Salary

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Location Press down arrow to select

Tampa:St Josephs

Details

Title

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.

The Denials Specialist-Utilization Review responsibilities include:

• Timely reviews of all payor, inpatient and outpatient claims, which have been denied, or may not meet medical necessity.
• Works closely with the Physician Advisors, Registration, Central Business Office (CBO), Central Authorization Unit(CAU), and Coding department team members.
• Maintains and coordinates a timely appeal process or effectuates a correction of billing status.
• Identifies and trends adverse determinations, and shares information with all stakeholders. Performs other duties as assigned by department leadership.

Position details:

• Location: Hybrid - Tampa/St Petersburg
• Status: Full time, 40 hours per week. Exempt
• Schedule: Monday - Friday 7:00 AM - 3:30 PM(can be flexible)
• Weekend Requirement: Occasional
• On Call: No

Certifications and Licensure:

• Required RN License
• Preferred Accredited Case Manager Certification
• Preferred Certified Case Manager

Education and Experience:

• Required 4 years RN experience with ASN and 2 years RN experience with BSN
• Required 2 years Utilization Review OR Care Coordination/Case Management OR Managed Care OR Finance experience
• Preferred Masters Degree in Nursing
• Preferred 6 months Denials Management
• Preferred 1 year Medicaid/Medicare experience

Benefits:

• Benefits (Health, Dental, Vision)
• Paid time off
• Tuition reimbursement
• 401k match and additional yearly contribution
• Yearly performance appraisals and team award bonus
• Community discounts and more

Equal Opportunity Employer Veterans/Disabled