DescriptionThe 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.
QualificationsMinimum 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.