Job Summary

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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Clinical Defense Auditor

Job Summary

Salary

Employment Type

Shift