[Hiring] CLINICAL APPEALS SPECIALIST @PRIORITY MANAGEMENT

Role Description

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

• 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.