Auditor, DRG Validation – CMS Audits

🔥 8 minutes 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 inpatient DRG claims using medical chart coding principles and client-specific guidelines • Review and interpret medical records independently • Apply in-depth coding knowledge to determine potential billing and coding issues • Draw on advanced clinical expertise and industry knowledge to substantiate conclusions • 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 • Identify 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 • Complete special projects and other assigned duties

🎯 Requirements

• Associate or bachelor’s degree in Health Information Management (RHIA or RHIT) • Alternatively, high school diploma or GED plus equivalent experience of 5+ years in claims auditing, quality assurance, or recovery auditing, ideally in a DRG / Clinical Validation Audit setting or a hospital environment • At least one required and maintained certification: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS • 5 to 7+ years of experience working with ICD-9/10CM, 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, and CMS and other regulatory compliance guidelines and mandates • Expert knowledge of DRG, APRDRG, 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 communicate with others to exchange information • Ability to assess the accuracy, neatness, and thoroughness of assigned work • Ability to provide a dedicated, secure work area • Ability to provide high-speed internet access/connectivity and office setup and maintenance • Ability to perform duties with or without reasonable accommodation

🏖️ Benefits

• Discretionary bonus consideration • Medical insurance coverage • Dental insurance coverage • Vision insurance coverage • Disability insurance coverage • 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 • Overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law