Description
The Clinical Defense Auditor will collaborate clinically with the patient care team and third parties to determine appropriateness and medical necessity of emergency care, admissions and specialty referrals.
Qualifications
Minimum Education
Bachelor's Degree RN, BSN preferred or extensive clinical experience in utilization management for healthcare. (Required)
Minimum Work Experience
3 years (Required)
- Three to five years of case management utilization review, or compliance related work experience in a hospital setting preferred. (Strongly Preferred)
- Experience with Technical Denials (Strongly Preferred)
Functional Accountabilities
Audits
- Compare and analyze billed charges to clinical records by department and specific line item to ensure accurate billing and reimbursement.
- Demonstrate clinical expertise by identifying all levels of care, treatments, pharmacological interventions and ancillary services provided.
- Coordinate chart reviews and problem identification and/or resolution with CNMC personnel and third party payers.
- Extract data from various sources to meet internal and external reporting requirements.
- Develop comprehensive statistical analysis of findings for both external reporting purposes and internal education for overall improvement.
Service Authorization
- Request and validate authorization of services from third party payers.
- Obtain authorization and utilize established protocols and third party payer contract requirements.
- Communicate potential denials with healthcare team for problem resolution.
- Document both services approved and denied.
Discharge Planning
- Collaborate with case management and healthcare team regarding specific patient discharge needs and goals.
- Contact third party payers to determine benefits and preferred providers for follow-up services outside the hospital.
- Coordinate patient discharges with Case Management Team.
Communication
- Communicate with payers in a clear, timely, accurate and professional manner to meet utilization management requirements.
- Communicate with the healthcare team third party payer information.
Performance Improvement
- Identify, implement and improve processes which impact customer service.
- Utilize agreed upon concurrent data collection techniques in Clinical Resource Management.
Organizational Accountabilities
Organizational Commitment/Identification
- Anticipate and respond to customer needs; follows up until needs are met.
Teamwork/Communication
- Demonstrate collaborative and respectful behavior.
- Partner with all team members to achieve goals.
- Receptive to others' ideas and opinions.
Performance Improvement/Problem-solving
- Contribute to a positive work environment.
- Demonstrate flexibility and willingness to change.
- Identify opportunities to improve clinical and administrative processes.
- Make appropriate decisions, using sound judgment.
Cost Management/Financial Responsibility
- Use resources efficiently.
- Search for less costly ways of doing things.
Safety
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