Auditor, Clinical Validation – Outpatient Specialty

🔥 13 hours ago

🇺🇸 United States – Remote

💵 $45 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

🦅 H1B Visa Sponsor

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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 outpatient and specialty claims, including APC, PNPP, pharmacy, and/or inpatient DRG claims • Perform coding and clinical chart validation for outpatient and specialty audits • Review and interpret medical records to identify billing and coding issues • Assess clinical review, coding accuracy, medical necessity, treatment setting, and services delivered • Apply medical chart coding principles and client-specific guidelines • Use Cotiviti Encoder and audit tools • Enter claims accurately into the Cotiviti system • Meet productivity, accuracy, quality, and valid claim identification/documentation standards • Identify potential claims outside the assigned audit concept where additional recoveries may be available • Suggest and develop audit concepts, process improvements, tools, and technological improvements • Implement ideas and approaches supporting audit production, communication, and client satisfaction • Evaluate information and draw logical conclusions • Complete responsibilities in the annual Performance Plan and special projects or other assigned duties

🎯 Requirements

• Associate or bachelor’s degree in nursing • Active/unrestricted nursing license • Coding certification required and maintained, such as 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 • Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology • Ability to learn and become proficient in outpatient and specialty review types • Adherence to official coding guidelines, Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates • Expert knowledge of DRG, ICD-10, CPT, and HCPCS codes • Excellent verbal and written communication skills • Ability to work independently and in a team environment • Ability to provide a dedicated, secure work area • Ability to provide high-speed internet access/connectivity and office setup and maintenance • Must be able to perform duties with or without reasonable accommodation

🏖️ Benefits

• Discretionary bonus consideration • Medical insurance • Dental insurance • Vision insurance • Disability insurance • Life insurance • 401(k) savings plan • Paid family leave • 9 paid holidays per year • 17–27 days of Paid Time Off (PTO) per year, depending on level and length of service • Overtime pay for nonexempt employees for hours worked over 40 per week or as required by state law • Remote work arrangement • Dedicated, secure work area and high-speed internet/office setup provided by the team member