Feb 01, 2024

Clinical Defense Auditor

  • Children's National Hospital
  • Washington, DC, USA

Job Description

Clinical Defense Auditor - (230001Q9) 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) 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   Primary Location: Maryland-Silver Spring Work Locations: Dorchester 12200 Plum Orchard Dr  Silver Spring 20904 Job: Nursing Organization: Finance Position Status: R (Regular) - FT - Full-Time Shift: Day Work Schedule: 8:30am - 5pm Job Posting: Oct 25, 2023, 2:20:07 PM