Clinical Appeals Specialist

1 week ago


Atlanta, Georgia, United States Piedmont Healthcare Corporate Full time

About the Role:

Piedmont Healthcare Corporate 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 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 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


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