RN Appeals Writer (Government Audit)

RESPONSIBLE FOR:

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.

MINIMUM EDUCATION REQUIRED:

Graduate from an accredited School of Nursing

MINIMUM EXPERIENCE REQUIRED:

Clinical experience in healthcare setting with a minimum of 7 years using electronic medical records or

acute hospital utilization review using InterQual or Milliman. Working knowledge of medical coding, case

management, government and contracted payers.

MINIMUM LICENSURE/CERTIFICATION REQUIRED BY LAW:

Current Georgia nursing licensure.

ADDITIONAL QUALIFICATIONS:

Experience in 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.