Clinical Appeals Specialist

1 week ago


Atlanta, Georgia, United States Piedmont Full time

JOB PURPOSE:


The primary responsibility involves a thorough examination, assessment, and extraction of clinical data from patient medical records. This role includes the composition of compelling narratives for Medicare and Medicaid appeals documentation and briefs to support denied cases throughout all stages of the governmental appeals process. The position requires an up-to-date understanding of medical coding, as well as federal and state hospital Utilization Review (UR) regulations and Medicare guidelines pertaining to medical necessity, inpatient, outpatient, and observation care.


Key Responsibilities:
  • Assist the Senior Director in 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 achieve optimal outcomes in response to process or guideline modifications that directly affect the RAC process.

Qualifications:


MINIMUM EDUCATION REQUIRED:
Graduation from an accredited School of Nursing.

Minimum Experience Required:
A minimum of seven (7) years of clinical experience in a healthcare environment utilizing electronic medical records or acute hospital utilization review with InterQual or Milliman methodologies.

Minimum Licensure / Certification Required By Law:
Current Registered Nurse License in the State of Georgia or NLC/eNLC Multistate License.

Additional Qualifications:
Proficient understanding of medical coding, case management, and interactions with government and contracted payers. Experience with clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites is preferred. Previous involvement in medical record auditing related to medical necessity claims is advantageous. IQCI Certification is preferred. Proficiency in Microsoft Word and Excel is also preferred. Familiarity with HealthPort systems is a plus.

#GD



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