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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
persuasive narratives for Medicare and Medicaid appeals documentation and briefs related to denied cases
under review at all levels of the governmental appeals framework; ensuring up-to-date knowledge of
medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines
pertaining to medical necessity, inpatient, outpatient, and observation services; supporting 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
achieve optimal outcomes in response to procedural or guideline modifications 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 utilizing electronic medical records or
acute hospital utilization review employing InterQual or Milliman. Familiarity with medical coding, case
management, and interactions with government and contracted payers.
Minimum Licensure/Certification Required By Law
Active nursing licensure in Georgia.
Additional Qualifications
Proficiency in clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites. Previous
experience in medical record auditing with claims of medical necessity; IQCI Certification is preferred.
Proficiency in Microsoft Word and Excel is preferred. Experience with HealthPort systems is an advantage.
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