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Clinical Appeals Specialist
2 months ago
Job Summary:
Piedmont is seeking a highly skilled Clinical Appeals Specialist to join our team. As a Clinical Appeals Specialist, you will be responsible for reviewing and analyzing patient medical records to draft effective narratives for Medicare and Medicaid appeals documentation and briefs.
Key Responsibilities:
- Conduct detailed reviews of patient medical records to extract clinical information and draft compelling narratives for appeals documentation and briefs.
- Maintain current knowledge of medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines regarding medical necessity, inpatient, outpatient, and observation.
- Collaborate with internal and external legal resources to facilitate the best possible outcomes in response to process or guideline changes that directly impact the RAC process.
- Assist the Senior Director with research and preparation for beneficiary hearings before the Administrative Law Judge (ALJ) and potentially testify as an expert witness in ALJ hearings.
Qualifications:
- Graduate from an accredited School of Nursing.
- Clinical experience in a healthcare setting with a minimum of 7 years using electronic medical records or acute hospital utilization review using InterQual or Milliman.
- Working knowledge of medical coding, case management, government, and contracted payers.
- Current Georgia nursing licensure.
- Experience in clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites.
- Previous experience with medical record auditing with medical necessity claims; IQCI Certification preferred.
- MicroSoft Word and Excel proficiency preferred. HealthPort systems experience a plus.
