CLINICAL APPEALS SPECIALIST (74626)

JOB SUMMARY:

In accordance with current federal and state guidelines as well as in accordance with our company’s established privacy policies and procedures; The Clinical Appeals Specialist is responsible for the comprehensive clinical review and production of supporting medical records in response to Medicare, Medicaid, and Insurance audits/appeals; risk adjustment/quality reviews; and legal/personal medical records requests.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Medical records review utilizing clinical and regulatory knowledge to determine required supporting documentation
• Clinical nursing review of patient records for compliance with facility practices and procedures as directed
• Flexibly manage tasks to meet deadlines by re-prioritizing workflows in a production-oriented setting
• Employ critical thinking to identify/resolve issues and provide timely feedback regarding medical review processes
• Develop appeal arguments using clinical evidence, supporting references/regulations, and participate in appeal hearings by providing testimony, as required
• Determine regulatory and clinical support for appeal arguments when pre-existing resources are unavailable
• Proficiently review and synthesize abstract information from handwritten/electronic medical records to support claims
• Agree not to disclose assigned user ID code and password for accessing resident/facility information and promptly report suspected or known violations of such disclosure to the Director of Medical Records.
• Agree not to disclose resident’s protected health information and promptly report suspected or known violations of such disclosure to the Director of Medical Records.
• Report any known or suspected unauthorized attempt to access facility’s information system to Director of Medical Records.
• Attend and participate in mandatory in-service training programs, workshops, seminars, etc., as approved / delegated.
• Ensure full compliance with HIPAA regulations
• Working knowledge of ICD-10, CPT coding, HCPCs, and MDS item coding for PPS/PDPM and OBRA assessments
• Proficiency in Medicare rules and regulations including coverage, benefit periods, certification, qualification criteria, 30-day rule, etc.
• Respond appropriately to behavioral, medical, and fire safety situations
• Other duties as assigned

SKILLS/COMPETENCIES

• Technology – Proficient in Microsoft 365 applications, including SharePoint, Teams, Lists, Excel, and Word; PDF editing software; and database systems to manage and retrieve information, track audit and appeal activity, prepare and submit documentation, and collaborate on shared files
• Analytical - Applies strong analytical skills to synthesize complex or diverse information, using experience and judgment to complement data
• Communication – Demonstrates strong written and verbal communication skills; presents information clearly and accurately; listens, seeks clarification, and responds effectively to questions; delivers group presentations; edits written work for spelling and grammar; adapts writing style to the audience and purpose
• Time Management and Independent Work – Prioritizes competing assignments, meets strict audit and appeal deadlines, and works independently in a remote setting
• Quality - Demonstrates accuracy and thoroughness; excellent attention to detail with a critical eye to catch/correct mistakes and errors; applies feedback to improve performance; monitors own work to ensure quality
• Problem Solving – Identifies/resolves problems in a timely manner; develops solutions; works well in group problem solving situations
• Dependability - Follows instructions and responds to management direction; takes responsibility for own actions; keeps commitments and completes tasks on time or notifies appropriate person with an alternate plan
• Character - Demonstrates integrity in every aspect of work and dealing with others; consistently models desired behaviors and values established by the company; respects diversity of perspective in discussions and demonstrates an inclusive style; demonstrates concerns for job safety for self and others

Organizational Support - Follows policies and procedures; completes administrative tasks correctly and on time; supports organization's goals and values

Qualifications

QUALIFICATIONS/EXPERIENCE:

Experience with documentation requirements for skilled rehabilitation and skilled nursing services, Minimum Data Set (MDS) coding, and/or medical necessity reviews and appeals in skilled nursing or post-acute care settings. Working knowledge of regulatory and payer reimbursement requirements and reasons for Medicare, Medicare Advantage, or Medicaid claim denials.

Completion of continuing education in case management, regulatory requirements, restorative nursing, medical record documentation, legal aspects of documentation, reimbursement, and compliance.

ADDITIONAL PREFERRED QUALIFICATIONS:

• Experience with Medicare Parts A and B and managed Medicaid.
• Background in therapy documentation and reimbursement review.
• Experience preparing Administrative Law Judge (ALJ) appeals, developing clinical arguments, organizing supporting evidence, and providing testimony at appeal hearings.
• RAC-CT certification; RAC-CTA certification is a plus.
• Experience reviewing clinical records in PointClickCare or a comparable electronic health record (EHR) system.