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Clinical Appeals Specialist
2 months ago
JOB PURPOSE:
The primary responsibility involves a comprehensive evaluation, analysis, and extraction of clinical data from patient medical records. This role requires drafting precise narratives for Medicare and Medicaid appeals documentation and briefs, supporting denied cases at all levels of the government appeals process. It is essential to maintain an up-to-date knowledge base of medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines concerning medical necessity, inpatient, outpatient, and observation care.
Key Responsibilities:
- Assist the Senior Director with research and preparation for beneficiary hearings before the Administrative Law Judge (ALJ).
- Potentially serve as an expert witness during ALJ hearings.
- Collaborate with both internal and external legal resources to ensure optimal outcomes in response to process or guideline changes impacting the RAC process.
Qualifications:
MINIMUM EDUCATION REQUIRED:
Graduate from an accredited School of Nursing.
Minimum Experience Required:
Seven (7) years of clinical experience in a healthcare environment utilizing electronic medical records or acute hospital utilization review using InterQual or Milliman.
Minimum Licensure / Certification Required By Law:
Current License in the State of Georgia as a Registered Nurse or NLC/eNLC Multistate License.
Additional Qualifications:
- Proficient understanding of medical coding, case management, and government and contracted payers.
- Experience with clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites is preferred.
- Prior experience in medical record auditing with medical necessity claims is advantageous.
- IQCI Certification is preferred.
- Proficiency in Microsoft Word and Excel is desirable.
- Experience with HealthPort systems is a plus.
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