Clinical Appeals Specialist

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  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
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