Job Description

Under the general supervision of the Director of Health Services, the position is responsible for appropriately and successfully executing clinical and administrative health plan denials in accordance with regulatory guidelines and plan policies.


1. Is responsible for managing all denials by conducting a comprehensive review of clinical documentation, clinical criteria/evidence-based guideline, policy, and or EOC/benefit policy.

2. Processes Medical Director or Behavior Health Practitioner denials in accordance with regulatory guidelines and plan policies.

3. Formulates a clear and concise clinically based or administrative argument to denial rationales supported by clinical criteria, including but not limited to, CMS, Florida Medicaid, CFR, Health Plan, InterQual (IQ), Milliman Care Guidelines (MCG), and UpToDate.

4. Complies with company and department policies and procedures to ensure timely and denials.

5. Follows Medicare/Medicaid’s denial rationale best practices.

6. Educates clinical and non-clinical staff within the guidelines of Leon Health’s policies and procedures and Medicare/Medicaid guidelines to assure competencies which are appropriate to accomplish duties and responsibilities productively and efficiently.

7. Monitors, evaluates, and prioritizes the quality, timeliness, and accuracy of prior authorization and concurrent denial reviews.

8. Is responsible for the data entry of denial decision communications to provider and members into the plan’s system, when applicable, in accordance with regulatory guidelines and plan policies.

9. Refers cases requiring further clinical review to a Medical Director or Behavior Health Practitioner as appropriate.


  • Knowledge of Dual Eligible Special Needs Plans, Centers for Medicare and Medicaid Services (CMS), and Florida Medicaid
  • Understanding/experience with InterQual, Milliman Care Guidelines, and other criteria used for medical necessity determinations.


  • Registered Nurse degree.


  • Minimum two (2) to five (5) years of experience in clinical reviews.
  • Medicare and/or Medicaid managed care experience