Auditor, Clinical Validation, Outpatient Specialty

🕒 May 21

🇺🇸 United States – Remote

💵 $95.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Cotiviti

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

⚕️ Healthcare Insurance

💳 Fintech

🤖 Artificial Intelligence

Healthcare Insurance • Fintech • Artificial Intelligence

Cotiviti is a healthcare technology and analytics company that specializes in improving payment accuracy and performance through advanced data analytics solutions. They partner with health plans, government agencies, and healthcare providers to deliver insights that enhance quality and efficiency in care delivery. With solutions such as risk adjustment, payment policy management, and member engagement, Cotiviti aims to optimize financial and clinical outcomes for the healthcare ecosystem.

📋 Description

• Audits Outpatient and Specialty Claims: Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims. • Draws on advanced coding expertise and industry knowledge to substantiate conclusions. • Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues. • Effectively Utilizes Audit Tools: Utilizes advanced proficiency, Cotiviti encoder and audit tools required to perform duties. • Meets or Exceeds Standards/Guidelines for Quality: A chieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation. • Identifies New Claim Types: Identifies potential claims outside of the concept where additional recoveries may be available. • Recommends New Concepts and Processes: Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience. • Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction.

🎯 Requirements

• Associate or bachelor’s degree in nursing (active /unrestricted license) • Coding Certification required and maintained i.e. CPC, CIC, CCS, CCS-P, RHIA or RHIT • 5 to 7 years of experience with clinical medical record coding or auditing • Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements • A broad knowledge of medical claims billing/payment systems provider billing guidelines • Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates • Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes • Excellent verbal and written communication skills. • Ability to work well in an individual and team environment.

🏖️ Benefits

• medical, dental, vision, disability, and life insurance coverage • 401(k) savings plans • paid family leave • 9 paid holidays per year • 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti