Clinical Defense Auditor

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 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