RN Clinical Appeals Analyst — Medical Necessity Expert

Florida Blue Group; Jacksonville (FL); Hybrid; USD 71,000 - 116,000; Full time

Benefits offered by this job

Medical insurance

Dental & Vision insurance

Retirement plan

Paid time off

Job summary

Florida Blue Group seeks a Registered Nurse with clinical experience to review provider appeals and determine medical necessity and coverage. You will examine medical documents, ensure proper coding, and coordinate with appeals teams to finalize determinations within required timelines.

Responsibilities include researching guidelines, interpreting coverage rules, and presenting cases to the Provider Appeal Panel. Familiarity with BCBSF systems and HIPAA is essential.

Qualifications

• RN set to state licensure (Florida) and related clinical experience.
• Familiarity with Medical Coverage Guidelines for medical necessity.
• Experience with HIPAA and ERISA requirements.

Responsibilities

• Review provider appeals and research medical documentation to reach a final determination.
• Review CMS-1500 forms or equivalents for proper coding.
• Access systems to review claim processing and assist with clinical research and processing of appeals.

Skills

RN licensure

Medical guidelines

HIPAA/ERISA knowledge

ICD-10 coding

Communication

Time management

Microsoft Office

Education

Bachelor’s degree or related equivalent

Job description

Florida Blue Group seeks a Registered Nurse with clinical experience to review provider appeals and determine medical necessity and coverage. You will examine medical documents, ensure proper coding, and coordinate with appeals teams to finalize determinations within required timelines.

Responsibilities include researching guidelines, interpreting coverage rules, and presenting cases to the Provider Appeal Panel. Familiarity with BCBSF systems and HIPAA is essential.