Auditor, Clinical Validation, DRG

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $45 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Cotiviti

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

Healthcare • Consulting • Logistics

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

• Audit inpatient claims with a focus on coding and clinical chart validation • Document audit results and evaluate clinical review, coding accuracy, treatment setting, and services delivered • Apply medical chart coding principles, clinical guidelines, advanced ICD-10 coding expertise, and industry knowledge to substantiate audit conclusions • Perform work independently • Use Cotiviti proprietary auditing systems to make audit determinations and generate audit letters • Meet productivity goals established by audit operations management • Meet accuracy and quality standards for valid claim identification and documentation, including letter writing • Identify new claim types and potential claims outside the audit concept where additional recoveries may be available • Suggest and develop high-quality, high-value concepts, process improvements, and tools • Complete annual Performance Plan responsibilities, special projects, and other assigned duties

🎯 Requirements

• Associate or bachelor’s degree in nursing with an active/unrestricted license; or associate or bachelor’s degree in Health Information Management with RHIA or RHIT; or high school diploma/GED plus equivalent 5+ years’ experience in claims auditing, quality assurance, or recovery auditing • At least one coding/CDI certification required and maintained: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS • 5 to 7+ years of experience working with ICD-9/10-CM, MS-DRG, AP-DRG, and APR-DRG • Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology • Adherence to official coding guidelines, Coding Clinic determinations, CMS and other regulatory compliance guidelines and mandates • Expert knowledge of DRG, APR-DRG, ICD-10, CPT, and HCPCS codes • Working knowledge of applicable industry-based standards • Proficiency in Word, Access, Excel, Teams, and other applications • Excellent written and verbal communication skills • Ability to perform duties with or without reasonable accommodation • Ability to provide a dedicated, secure work area, high-speed internet connectivity, and office setup/maintenance • Ability to remain stationary, often standing or sitting for prolonged periods, and repeat motions involving wrists, hands, and/or fingers

🏖️ Benefits

• Discretionary bonus consideration • Medical insurance coverage • Dental insurance coverage • Vision insurance coverage • Disability insurance coverage • Life insurance coverage • 401(k) savings plan • 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 • Overtime pay for nonexempt employees for hours worked over 40 per week, or as required by applicable state law • Dedicated, secure work area and high-speed internet/office setup supported as a working condition