Clinical Validation Auditor - Coding and Documentation

Job Requirements

POSITION SUMMARY

To be fully engaged in providing excellence by performing clinical validation and audit reviews, drafting and processing appeals for denials, and reporting trends discovered working collaboratively as a key member of a multidisciplinary team.

PRIMARY ACCOUNTABILITES

• Interpret clinical documentation to ensure the health record clearly and consistently supports all diagnoses and procedure codes reported and that it upholds regulatory compliance by consulting and referencing validated coding and documentation references for accurate code assignment and sequencing rules.
• Compose appeal letters to governmental and private payers on denials received with clear and effective communication, to include appropriate references, in the validation of the clinical diagnoses as documented in the clinical record. Process appeal letters to payers designated point of contact and ensure timely receipt by payer or auditing agency.
• Provides data entry of all data regarding denials and appeals, specifically information which results in unfavorable trends.
• Collaborates with Manager, Director, and possibly physician administration communicating physician documentation trends to ensure individual physician communication is delivered in the most agreeable manner.
• Perform daily prebill clinical validation audits in coordination with the Inpatient DRG Auditors on accounts that meet specific guidelines for trending OIG, payor specific or CMS target diagnoses. Record findings for monthly compilation and reporting.
• Request clarification from provider when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element.
• Audits and abstracts new technology add on payment (NTAP) diagnoses and procedure codes.
• Provides timely notification to medical records/registration personnel of any identified discrepancies of patient information in the medical record.
• Work in partnership with representatives from the Patient Financial Service appeals department to ensure accounting and reconciliation of all denials and appeal letters.
• Provide ongoing education to physicians, CDI and Coding staff regarding clinical validation audit findings for documentation improvement, physician query opportunities and correct coding, under the supervision of the Auditing Manager and/or the Director of Coding and Clinical Documentation.
• Attends monthly department meetings and bi-monthly coding/CDI roundtables.
• Maintain and observes patient confidentiality as outlined in the National Patient Safety Goals and HIPAA guidelines that protects the confidentiality of the health record and refuse to access protected health information not required for clinical or coding validation-related services.
• Knowledge of structure and content of the electronic health record displaying ability and competency to navigate the EHR accurately and efficiently for reviewing codes/DRG assigned and validation of documented clinical diagnoses.
• Other duties and responsibilities as assigned by the Auditing Manager

Work Experience

MINIMUM QUALIFICATIONS

• Education: Graduate of nursing school (RN or LPN)
• Work Experience: 2 years nursing and/or clinical documentation experience.
• Licensure: RN or LPN
• Certification: Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Improvement Practitioner (CDIP)
• Work Experience in lieu of Certification: 5 years nursing or clinical documentation experience.
• Skills/Knowledge/Abilities:
• Proficient in Microsoft Office Outlook, Word, Excel, PowerPoint.
• Ability to work autonomously with minimal supervision.
• Excellent precise written and oral communication skills for professional interaction and presence.
• Excellent problem solving, analytical, and critical thinking skills.
• Demonstrate the highest standard of customer service skills.
• Ability to work well under time pressure meeting deadlines.
• Must be detail oriented.
• Ability to muti-task.
• Must be flexible, accountable, and dependable.

PREFERRED QUALIFICATIONS

• Work Experience: 3 years clinical documentation experience and 1-year DRG/clinical validation auditing experience.

PHYSICAL REQUIREMENTS

• Majority of time involves sitting or standing; occasional walking, bending, and stooping.
• Long periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

Benefits

ABOUT HEALTH FIRST

At Health First, diversity and inclusion are essential for our continued growth and evolution. Working together, we strive to build and nurture a culture that recognizes, encourages, and respects the diverse voices of our associates. We know through experience that different ideas, perspectives, and backgrounds create a stronger and more collaborative work environment that delivers better results. As an organization, it fuels our innovation and connects us closer to our associates, customers, and the communities we serve.

Schedule : Full-Time

Shift Times : 800am430pm

Paygrade : PG-PG-PG-38