Clinical Defense Auditor

4 weeks ago

Silver Spring, United States Children's National Full time

Minimum Education

Bachelor's Degree RN, BSN preferred or extensive clinical experience in utilization management for healthcare. (Required)

Minimum Work Experience

3 years (Required)

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 identify 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 health care 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 Accountabilities (Staff)
Organizational Commitment/Identification

Anticipate and responds 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

Speak up when team members appear to exhibit unsafe behavior or performance


Continuously validate and verify information needed for decision making or documentation


Stop in the face of uncertainty and takes time to resolve the situation


Demonstrate accurate, clear and timely verbal and written communication


Actively promote safety for patients, families, visitors and co-workers


Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance

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