Clinical Validation Auditor - Coding and Documentation Job Rockledge area,Florida USA,Healthcare

Clinical Validation Auditor

The Clinical Validation Auditor performs 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 Responsibilities

Interprets 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.

Composes 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 leadership and possibly physician administration communicating physician documentation trends to ensure individual physician communication is delivered in the most agreeable manner.

Performs daily prebill clinical validation audits in coordination with the Inpatient DRG Auditors on accounts that meet specific guidelines for trending Office of Inspector General (OIG), payor specific or CMS target diagnoses. Record findings for monthly compilation and reporting.

Requests clarification from licensed practitioner 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.

Gives timely notification to medical records and registration personnel of any identified discrepancies of patient information in the medical record.

Works in partnership with representatives from the Patient Financial Service appeals department to ensure accounting and reconciliation of all denials and appeal letters.

Delivers 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.

Maintains and observes patient confidentiality as outlined in the National Patient Safety Goals and Health Insurance Portability and Accountability Act (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.

Conducts additional duties and responsibilities as assigned by leadership.

Work Experience

Minimum Qualifications

Education:

Any one of the following:

Associate's degree in nursing (ASN) or Nursing Diploma OR
Technical Diploma in Practical Nursing OR
Completion of a Health Information Management Training Program.

Work Experience:

One (1) year clinical documentation improvement or auditing experience.

Licensure:
Any one of the following:

Registered Nurse (RN) licensure in the State of Florida OR
Licensed Practical Nurse (LPN) licensure in the State of Florida.

Certification:
None

Certification In Lieu of Licensure:
Any one of the following:

Registered Health Information Administrator (RHIA) certification from the American Health Information Management Association (AHIMA) OR
Registered Health Information Technician (RHIT) certification from the American Health Information Management Association (AHIMA)

Skills/Knowledge/Abilities:

Proficient in Microsoft Office – Outlook, Word, Excel, PowerPoint.
Knowledge of structure and content of the electronic health record displaying ability and competency to navigate the electronic health record accurately and efficiently for reviewing codes/DRG assigned and validation of documented clinical diagnoses.
Ability to work autonomously with minimal supervision.
Strong critical thinking skills.
Strong communication skills and…