Clinical Narrative Specialist
6 days ago
About the Role:
In this role, you will be responsible for drafting high-quality narratives in support of denied cases under appeal at all levels of the government appeals process. You will work closely with our Senior Director to research and prepare for beneficiary hearings before the Administrative Law Judge (ALJ). Your expertise as an RN will be invaluable in testifying as an expert witness in ALJ hearings and collaborating with internal and external legal resources to achieve the best possible outcomes.
Responsibilities:
* Review and analyze patient medical records to extract relevant clinical information
* Draft effective narratives for Medicare and Medicaid appeals documentation and briefs
* Maintain current knowledge of medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines regarding medical necessity, inpatient, outpatient, and observation
* Collaborate with Senior Director on research and preparation for beneficiary hearings before the Administrative Law Judge (ALJ)
* Testify as expert witness in ALJ hearings
* Work with internal and external legal resources to facilitate the best possible outcomes in response to process or guideline changes that directly impact the RAC process
Qualifications:
* Graduate from an accredited School of Nursing
* Minimum 7 years of clinical experience in a healthcare setting 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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