Description:
JOB PURPOSE:
Detailed review, analysis and extraction of clinical information from patient medical records and drafting of effective narratives for Medicare and Medicaid appeals documentation and briefs in support of denied cases under appeal at all levels of the government appeals process; maintaining current knowledge base of medical coding, federal and state hospital Utilization Review (UR) regulations and Medicare guidelines regarding medical necessity, inpatient, outpatient and observation; assisting Senior Director with research and preparation for beneficiary hearings before the Administrative Law Judge (ALJ); potentially testifying as expert witness in ALJ hearings; collaborating with internal and external legal resources in an effort to facilitate the best possible outcomes in response to process or guideline changes that directly impact the RAC process.

Qualifications:
MINIMUM EDUCATION REQUIRED:
Graduate from an accredited School of Nursing.

MINIMUM EXPERIENCE REQUIRED:
Seven (7) years of clinical experience in a healthcare setting using electronic medical records or acute hospital utilization review using InterQual or Milliman.

MINIMUM LICENSURE / CERTIFICATION REQUIRED BY LAW:
Current License in the State of Georgia as a Registered Nurse or NLC/eNLC Multistate License.

ADDITIONAL QUALIFICATIONS:
Working knowledge of medical coding, case management, government and contracted payers.
Experience in clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites is desired. 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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