RN Utilization Review Specialist — Hybrid, Great Benefits

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

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.