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Clinical Appeals Specialist
2 months ago
PRIMARY RESPONSIBILITIES:
Thorough examination, assessment, and extraction of clinical data from patient medical records, along with the composition of
effective narratives for Medicare and Medicaid appeals documentation and briefs supporting denied cases
under review at all stages of the governmental appeals process. Keeping up-to-date with
medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines
pertaining to medical necessity, inpatient, outpatient, and observation care. Assisting the Senior Director with research
and preparation for beneficiary hearings before the Administrative Law Judge (ALJ); potentially serving
as an expert witness in ALJ hearings; collaborating with both internal and external legal resources to
ensure optimal outcomes in response to process or guideline changes that directly affect the
RAC process.
Qualifications
MINIMUM EDUCATION REQUIRED:
Graduation from an accredited School of Nursing.
Minimum Experience Required
Clinical experience in a healthcare environment with at least 7 years of utilizing electronic medical records or
acute hospital utilization review employing InterQual or Milliman methodologies. Proficient understanding of medical coding, case
management, and interactions with government and contracted payers.
Minimum Licensure/Certification Required By Law
Current nursing licensure in Georgia.
Additional Qualifications
Familiarity with clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites. Previous
experience in medical record auditing concerning medical necessity claims; IQCI Certification is preferred.
Proficiency in Microsoft Word and Excel is preferred. Experience with HealthPort systems is a plus.
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