Clinical Appeals Specialist

1 day ago


Atlanta, Georgia, United States Piedmont Full time
Job Summary

Piedmont 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.

Key Responsibilities
  • Conduct detailed reviews of patient medical records to extract relevant clinical information
  • Draft compelling narratives to support denied cases under appeal
  • Stay up-to-date with medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines
  • Collaborate with internal and external legal resources to ensure the best possible outcomes
  • Potentially testify as an expert witness in Administrative Law Judge (ALJ) hearings
Requirements
  • Graduate from an accredited School of Nursing
  • Seven (7) years of clinical experience in a healthcare setting using electronic medical records or acute hospital utilization review
  • Current License in the State of Georgia as a Registered Nurse or NLC/eNLC Multistate License
  • Working knowledge of medical coding, case management, government and contracted payers
  • Experience with clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites
Preferred Qualifications
  • IQCI Certification
  • MicroSoft Word and Excel proficiency
  • HealthPort systems experience


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