Georgia Licensed Clinical Audit Specialist

Job Summary

Supporting clinical operations, the full-time Georgia Licensed Clinical Audit Specialist will process, track, and appeal clinical denials while facilitating the development and implementation of Utilization Management data collection methodologies remotely.

Key responsibilities:

• Process and appeal clinical denials, ensuring compliance with industry guidelines
• Analyze data to identify trends and develop actionable plans in collaboration with the clinical team
• Facilitate the design and implementation of Utilization Management studies within functional areas

Required qualifications:

• Graduate of an accredited school of nursing with strong clinical case management experience
• Three years of experience in Utilization Management/Case Management or a related field
• Knowledge of coding, billing, audit, and reimbursement payer methodologies and guidelines
• Experience in data collection, interpretation, and presentation to medical staff
• Familiarity with interacting with managed care companies, including appealing denials