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Emory Healthcare/Emory University Clinical Appeals Specialist RN, Infusion Precertification in Atlanta, Georgia


The shift for this position is 8a-5:30p

JOB DESCRIPTION: The Clinical Appeals Specialist, RN is responsible for reviewing and responding to a provider second level clinical appeals. The Clinical Appeals Specialist, RN will provide feedback regarding the outcome of the appeals review to the Associated Director of Audit and Compliance. Other responsibilities will include reviewing denial letters, determination and data entry of audit recommendations and responsibility for professional and effective responses that are submitted timely under payer timeframes. The Clinical Specialist may also be responsible for performing and coordinating peer reviews for specific accounts. Reviews medical records for validation of denials and prepares appeals strategy; creates denial letter rationale and formulated custom appeal response letters utilizing strong critical thinking skills to independently access cases for strengths and weaknesses within the appeals spectrum. Constructs and documents a brief and fact-based case utilizing compelling clinical evidence from the medical record; supported by current industry clinical guidelines, evidence based medicine and official coding guidelines. Applies strong writing and grammar skills to formulate professional appeal letters that clearly support each appeal argument. Accurately abstracts denial audit findings into our proprietary application system according to standard procedures. Utilizes audit reference tools and application to report and analyze denial trends and collected/lost revenue. Prepares reports in the subscribed manner complying with government and legal program standards to support appeals program objectives. Will be responsible for creating trending reports in order to communicate denial trends and audit findings to upper management and department leads. Will be responsible for working with upper management and department leads to create process improvement and decrease the denial volume related to audit. Works independently to meet or exceed productivity and accuracy goals. Attends education workshops, webinars, etc., for coding and documentation integrity and compliance.

MINIMUM QUALIFICATIONS: Graduate of an accredited School of Nursing and have a valid, active unencumbered Nursing license or temporary permit approved by the Georgia Licensing Board. Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS) preferred. Certified Clinical Documentation Specialist (CCDS) a plus.

PHYSICAL REQUIREMENTS: 1-10 lbs 0-33% of the work day (occasionally), negligible 34-66% of the workday (frequently), negligible 67-100% of the workday (constantly). Lifting 10 lbs max, carrying of small articles such as dockets, ledgers, files, small tools, occasional standing & walking, frequent sitting, close eye work (computers, typing, reading, writing), Physical demands may vary depending on assigned work area and work tasks.

ENVIRONMENTAL FACTORS: Factors affecting environment conditions may vary depending on the assigned work area and tasks. Environmental exposures include, but are not limited to: Blood-borne pathogen exposure, Bio-hazardous waste. chemicals/gases/fumes/vapors, communicable diseases, electrical shock, floor surfaces, hot/cold temperatures, indoor/outdoor conditions, latex, lighting patient care/handling injuries, radiation, shift work, travel may be required, use of personal protective equipment, including respirators, environmental conditions may vary depending on assigned work area and work tasks.

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Division Emory Healthcare Inc.

Campus Location Atlanta, GA, 30345

Campus Location US-GA-Atlanta

Department EHI Infusion Precert

Job Type Regular Full-Time

Job Number 99040

Job Category Clinical & Nursing Support

Schedule 8a-5:30p

Standard Hours 40 Hours

Emory Healthcare is an Equal Employment Opportunity employer committed to providing equal opportunity in all of its employment practices and decisions. Emory Healthcare prohibits discrimination, harassment, and retaliation in employment based on race, color, religion, national origin, sex, sexual orientation, gender identity or expression, pregnancy, age (40 and over), disability, citizenship, genetic information, service in the uniformed services, veteran status or any other classification protected by applicable federal, state, or local law.