RN Appeals Writer - Remote

Piedmont-Healthcare; Atlanta (GA); Remote; USD 85,000 - 105,000; Full time

Job summary

Piedmont Healthcare is seeking a qualified nurse to perform detailed review and extraction of clinical data from patient records and draft narratives for Medicare/Medicaid appeals, supporting RAC processes.

The role requires staying current with Utilization Review regulations and Medicare guidelines, assisting with beneficiary hearings before ALJ, and collaborating with internal/external legal resources to adapt to guideline changes.

Qualifications

• RN licensed in Georgia with nursing degree from an accredited program.
• 7 years' clinical experience and/or utilization review in healthcare.
• Experience with medical record auditing and medical necessity claims.
• Familiarity with InterQual or Milliman in UR/Utilization contexts.

Responsibilities

• Review clinical information from patient records and draft narratives for Medicare/Medicaid appeals.
• Support RAC process and assist in beneficiary hearings preparation; may testify as expert witness.

Skills

Clinical data extraction

Medical records review

Medicare/Medicaid appeals

RAC process knowledge

Narrative writing

InterQual/Milliman

Education

Graduate from an accredited School of Nursing

Georgia RN License

IQCI Certification Preferred

NLC/eNLC Multistate License

Tools

EPIC

SCM / Quest

STAR

I-Suites

Client Tracking

Job description

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

Work Experience

• 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

Licenses and Certifications

• Current License in the State of Georgia as a Registered Nurse or NLC/eNLC Multistate License Required
• IQCI Certification Preferred

Business Unit : Company Name

Piedmont Healthcare Corporate