Job Requirements
POSITION SUMMARY
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 ACCOUNTABILITES
- 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.
2. 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.
3. Provides data entry of all data regarding denials and appeals, specifically information which
results in unfavorable trends.
4. Collaborates with leadership and possibly physician administration communicating physician
documentation trends to ensure individual physician communication is delivered in the most
agreeable manner.
5. 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.
6. 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.
7. Audits and abstracts new technology add on payment (NTAP) diagnoses and procedure codes.
8. Gives timely notification to medical records and registration personnel of any identified
discrepancies of patient information in the medical record.
9. Works in partnership with representatives from the Patient Financial Service appeals
department to ensure accounting and reconciliation of all denials and appeal letters.
10.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.
11. 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.
12. Conducts additional duties and responsibilities as assigned by leadership
Work Experience
MINIMUM QUALIFICATIONS
Education: Any one of the following:
o associate’s degree in nursing (ASN) or Nursing Diploma OR
o Technical Diploma in Practical Nursing OR
o 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:
o Registered Nurse (RN) licensure in the State of Florida OR
o Licensed Practical Nurse (LPN) licensure in the State of Florida.
- Certification: None
- Certification In Lieu of Licensure: Any one of the following:
o Registered Health Information Administrator (RHIA) certification from the American
Health Information Management Association (AHIMA) OR
o Registered Health Information Technician (RHIT) certification from the American Health
Information Management Association (AHIMA)
- Skills/Knowledge/Abilities:
o Proficient in Microsoft Office – Outlook, Word, Excel, PowerPoint.
o 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.
o Ability to work autonomously with minimal supervision.
o Strong critical thinking skills.
o Strong communication skills and professional presence.
o Ability to maintain composure in stressful office environment.
o Provide professional, precise, and complete communication.
o Demonstrate the highest standard of customer service skills.
o Ability to work well under time pressure meeting deadlines.
o Strong analytical skills.
o Flexibility.
o Accountability and dependability.
PREFERRED QUALIFICATIONS
o Two (2) years’ clinical documentation improvement experience.
One (1) years DRG auditing experience.
o Certified Coding and Documentation Specialist (CCDS) certification.
o Certified Document Improvement Practitioner (CDIP) certification.
o Certified Coding Specialist (CCS) certification.
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-PG-PG-38
