The Clinical Review Appeals Auditor is responsible for performing accurate Clinical Validation Audits of inpatient medical records to validate diagnoses. The Clinical Review Appeals Auditor responds to provider appeals, rebuttals, and disputes received in response to Clinical Validation audits. The Clinical Review Auditor works closely with DRG analysts and provides clinical insight for DRG validations as necessary.
Clinical Validation Auditor
Overview of Position
The Clinical Review Auditor is responsible for performing accurate Clinical Validation Audits of inpatient medical records to validate diagnoses. The Clinical Review Auditor also screens claim data and responds to provider appeals. The Clinical Review Auditor works closely with DRG Analysts and provides clinical insight for DRG validations as necessary.
What will be my duties and responsibilities in this job?
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Performs Clinical Validation Audits by applying extensive knowledge of clinical criteria and guidelines accurately and objectively while maintaining productivity targets.
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Demonstrates ability to appropriately apply clinical criteria to a variety of claims scenarios and effectively utilize audit tools to maximize savings.
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Demonstrates ability to research clinical criteria and evaluate it for accuracy, quality, and to ensure it meets accepted standards of medical practice.
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Works independently to meet or exceed productivity and accuracy goals.
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Communicates audit findings with excellent grammar and writing skills.
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Performs appeal reviews and responds to provider disputes for Clinical Validation Audits.
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Screens claims data including MS-DRG, AP-DRG, and APR-DRG data.
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Interfaces with Physician advisors, Coders, and other members of the audit team.
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Maintains current knowledge of clinical guidelines, reimbursement trends, and client expectations.
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Demonstrates commitment to Change Healthcare core values.
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The position responsibilities outlined above are in no way to be construed as all encompassing. Other duties, responsibilities, and qualifications may be required and/or assigned as necessary.
What are the requirements needed for this position?
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An active and unrestricted RN license
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3 years of clinical nursing experience in the inpatient setting
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3 years of inpatient coding experience including documented competency in both ICD-9 and ICD-10; or 3 years of inpatient CDI experience; or equivalent experience
What critical skills are needed for you to consider someone for this position?
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Ability to perform in-depth analysis of clinical documentation relating to diagnoses
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Proficiency with MS Office along with good ability to learn new systems
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Excellent spoken and written communication skills
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Excellent analytical skills
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High level organizational and prioritization skills with the ability to manage multiple, concurrent projects and tasks effectively
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Ability to be decisive and work well independently
What other skills/experience would be helpful to have?
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Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) a plus
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Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) a plus
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Degree from accredited college or university
What are the working conditions and physical requirements of this job?
How much should I expect to travel?
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No travel required
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COVID Mandate
As a federal contractor, Change Healthcare is adhering to the Executive Order which mandates vaccination. As such, we are requiring all U.S. new hires and employees to show proof of being fully vaccinated for COVID-19 or receive an approved accommodation by their date of hire, as a condition of employment.
As we continue to navigate the ever-changing COVID-19 pandemic, we remain committed to doing our part to ensure the health, safety, and well-being of our team members and our communities. Proof of vaccination or accommodations requests will be collected once an offer is accepted with Change Healthcare. All accommodation requests will be carefully considered but are not guaranteed to be approved.
Equal Opportunity/Affirmative Action Statement
Change Healthcare is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, sexual orientation, gender identity, genetic information, national origin, disability, or veteran status. To read more about employment discrimination protections under federal law, read EEO is the Law at https://www.eeoc.gov/employers/eeo-law-poster and the supplemental information at https://www.dol.gov/ofccp/regs/compliance/posters/pdf/OFCCP_EEO_Supplement_Final_JRF_QA_508c.pdf.
If you need a reasonable accommodation to assist with your application for employment, please contact us by sending an email to [email protected] with “Applicant requesting reasonable accommodation” as the subject. Resumes or CVs submitted to this email box will not be accepted.
Click here https://www.dol.gov/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf to view our pay transparency nondiscrimination policy.
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Change Healthcare maintains a drug free workplace and conducts pre-employment drug-testing, where applicable, in accordance with federal, state and local laws.
Source: Indeed.com
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