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Medical Necessity Reviewer

2 months ago

Atlanta, Georgia, United States Piedmont Healthcare Corporate Full time

About the Role:

Piedmont Healthcare Corporate is seeking a skilled Clinical Appeals Specialist to join our team. As a key member of our appeals process, 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 relevant clinical information
  • Draft and edit narratives for appeals documentation and briefs
  • Stay up-to-date with current knowledge of medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines
  • Collaborate with internal and external legal resources to facilitate the best possible outcomes in response to process or guideline changes
  • Assist the Senior Director with research and preparation for beneficiary hearings before the Administrative Law Judge (ALJ)
  • Potentially testify as an expert witness in ALJ hearings

Requirements:

  • 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 with 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