Hybrid Clinical Appeals Specialist

GuideWell; Jacksonville (FL); Hybrid; USD 71,000 - 116,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

Retirement savings plan

Paid time off

Job summary

GuideWell in Florida seeks an experienced RN to review provider appeals and medical documentation to determine medical necessity and adherence to guidelines. You will work with BCBSF systems, draft final statements, and support the Provider Appeal Panel.

The role requires 2+ years of clinical experience, Florida RN licensure, and knowledge of HIPAA/ERISA. It offers a hybrid schedule, competitive pay, and comprehensive benefits including medical, dental, and retirement plans.

Qualifications

• 2+ years related work experience in clinical appeals or utilization management.
• Experience with medical guidelines and regulatory requirements (HIPAA/ERISA).
• Ability to interact with internal and external customers professionally.
• Knowledge of ICD-10 coding principles is preferred.

Responsibilities

• Review and research provider appeals to reach final determination.
• Review provider appeal and medical documentation.
• Review CMS-1500 forms for proper coding.
• Prepare and present clinical appeal cases to the Provider Appeal Panel.

Skills

Clinical experience

Education

RN license Florida

Bachelor’s degree or equivalent

Tools

Microsoft Office

BCBSF systems (Legacy/Diamond/Siebel)

Job description

GuideWell in Florida seeks an experienced RN to review provider appeals and medical documentation to determine medical necessity and adherence to guidelines. You will work with BCBSF systems, draft final statements, and support the Provider Appeal Panel.

The role requires 2+ years of clinical experience, Florida RN licensure, and knowledge of HIPAA/ERISA. It offers a hybrid schedule, competitive pay, and comprehensive benefits including medical, dental, and retirement plans.