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Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role:

Job Summary

Clinical Review Specialist works with Medicaid and Disability team and other key stakeholders (e.g., Case Management, Social Workers, Patient Access Service Center teams) in order to provide clinical screening assessments of prospective Medicaid or Disability candidates and will assist patients and families with navigating through the Medicaid or Disability application process. The position will further provide medical record analysis and other clinical expertise in order to support the functions of the department; for example will review medical records in order to make a determination of emergency services provided. This position will also provide coverage for precertification tasks as needed.

Minimum Job Qualifications

• Licensure or other certifications: LPN

• Educational Requirements: Associates Degree

• Minimum Experience: A minimum of three (3) years in professional nursing and at least one year of UR, Case Management and/or Auditing experience

• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications: RN

• Preferred Educational Requirements: Bachelors Degree

• Preferred Experience:

• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Ability to analyze medical records, including but not limited to physician orders, clinical notes, and coding

• Exceptional research and problem-solving skills

• Deep knowledge of Patient Financial Services processes and procedures, including governmental guidelines and protocols, the components of full verification, and payer information / medical necessity requirements

• Exemplary customer service skills and the ability to assist others in a pleasant, courteous and professional manner

• Excellent oral and written communication skills required

• Ability to serve as a clinical expert resource to all Medicaid and Disability personnel and other internal and external departments

Essential Tasks and Responsibilities

• Works with Medicaid and Disability team and other key stakeholders (e.g., Case Management, Social Workers, Patient Access Service Center teams) in order to provide clinical screening assessments of prospective Medicaid or Disability candidates.

• Completes timely and accurate review of patient's medical record in order to determine medical necessity of procedure(s) performed, patient's long-term prognosis and follow-up care needs; determines if criteria for emergency services were met via records reviews and completes requisite forms.

• Navigates patient and or patient's family through the application process for Medicaid or Disability; also supports/performs tasks related to the precertification, claims denials, and appeals processes. Performs insurance defense audits.

• Audits applications and appeal documentation to ensure accuracy and completeness.

• Communicates and implements, in an accurate and timely manner, process change as needed to accommodate high volume and other unforeseen circumstances that may arise.

• Completes precertification functions as needed.

• Participates in education and training efforts to maintain competency in ever changing environment. Maintains clinical licensure.

• Teams with other departments to improve performance of the revenue cycle. Provides support and guidance to problem-solving and process improvement initiatives.

• Performs other duties as assigned or requested.

Physical Demands

• Weight Lifted: Up to 20 lbs, Occasionally 0-30% of time

• Weight Carried: Up to 20 lbs, Occasionally 0-30% of time

• Vision: Moderate, Occasionally 0-30% of time

• Kneeling/Stooping/Bending: Occasionally 0-30%

• Standing/Walking: Occasionally 0-30%

• Pushing/Pulling: Occasionally 0-30%

• Intensity of Work: Frequently 31-65%

• Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding

Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS: Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.