CVA- Clinical Validation Analyst

Description:

Responsibility:

The Clinical Review Auditor has an extensive clinical and reimbursement background and is responsible for auditing inpatient medical records and applying clinical criteria and guidelines to ensure documented diagnoses are clinically valid.

The Clinical Review Auditor also screens claims data and responds to provider appeals, rebuttals, and disputes.

The Clinical Review Auditor works closely with DRG analysts and provides clinical insight for DRG validations as necessary

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Primary Duties/Responsibility

1: Performs Clinical Validation Audits by applying extensive knowledge of clinical criteria and guidelines accurately and objectively while maintaining productivity targets.

o  25%

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Primary Duties/Responsibility

2: Demonstrates ability to appropriately apply clinical criteria to a variety of claims scenarios and effectively utilize audit tools to maximize savings.

o  15%

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Primary Duties/Responsibility

3: Demonstrates ability to research clinical criteria and evaluate it for accuracy, quality, and to ensure it meets accepted standards of medical practice.

o  15%

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Primary Duties/Responsibility

4: Performs appeal reviews and responds to provider disputes for Clinical Validation Audits.

o  15%

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Primary Duties/Responsibility

5: Screens claims data including MS-DRG, AP-DRG, and APR-DRG data.

o  10%

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Primary Duties/Responsibility

6: Interfaces with Physician advisors, Coders, and other members of the audit team.

o  10%

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Primary Duties/Responsibility

7: Maintains current knowledge of clinical guidelines, reimbursement trends, and client expectations.10%

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• Communicates audit findings with excellent grammar and writing skills.
• ·  Performs appeal reviews and responds to provider disputes for Clinical Validation Audits.
• ·  Interfaces with Physician advisors, Coders, and other members of the audit team.

• · Performs appeal reviews and responds to provider disputes for Clinical Validation Audits.
• · Screens claims data including MS-DRG, AP-DRG, and APR-DRG data.

• ·Maintains current knowledge of clinical guidelines, reimbursement trends, and client expectations.

• ·Interfaces with Physician advisors, Coders, and other members of the audit team.

Requirements:

Requirements:

• Ability to perform in-depth analysis of clinical documentation relating to diagnoses

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• Ability to use software, hardware, and peripherals related to job responsibilities, including MS Office
• Excellent spoken and written communication skills
• Excellent analytical, organizational, and prioritization skills
• Ability to multi-task in a fast-paced environment
• Ability to be decisive and work independently
• Communicates audit findings with excellent grammar and writing skills.
• 3 years of clinical nursing experience in the inpatient setting
• 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
• An active and unrestricted RN license
• Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS) preferred
• Certified Documentation Improvement Practitioner (CDIP) or Certified Clinical Documentation Specialist (CCDS) preferred