Clinical Defense Auditor

3 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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