RN Appeals Writer – RAC for Home Health and Hospice

Piedmont Healthcare Inc. • Vinings, GA

8d

About The Position

This role involves the detailed review, analysis, and extraction of clinical information from patient medical records. The primary responsibility is to draft effective narratives for Medicare and Medicaid appeals documentation and briefs to support denied cases at all levels of the government appeals process. The position requires maintaining a current knowledge base of medical coding, federal and state hospital Utilization Review (UR) regulations, and Medicare guidelines concerning medical necessity, inpatient, outpatient, and observation care. Additionally, the role includes assisting the Senior Director with research and preparation for beneficiary hearings before the Administrative Law Judge (ALJ), potentially testifying as an expert witness in these hearings, and collaborating with internal and external legal resources to achieve the best possible outcomes in response to changes impacting the RAC process.

Requirements

• Graduate from an accredited School of Nursing
• 7 years of clinical experience in a healthcare setting using electronic medical records or acute hospital utilization review using InterQual or Milliman
• Previous experience with medical record auditing with medical necessity claims
• Current License in the State of Georgia as a Registered Nurse or NLC/eNLC Multistate License

Nice To Haves

• Experience in clinical software such as SCM / Quest, STAR, EPIC, Client Tracking, and I-Suites
• IQCI Certification

Responsibilities

• Detailed review, analysis and extraction of clinical information from patient medical records
• 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

What This Job Offers

• Job Type: Full-time
• Career Level: Senior