Overview
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.Responsibilities
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
Education- Graduate from an accredited School of Nursing Required
- 7 years of clinical experience in a healthcare setting using electronic medical records or acute hospital utilization review using InterQual or Milliman Required
- Previous experience with medical record auditing with medical necessity claims Required
- Experience in clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites is Preferred
- Current License in the State of Georgia as a Registered Nurse or NLC/eNLC Multistate License Required
- IQCI Certification Preferred