DRG Validation Auditor, Clinical & Coding

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $45.6k / 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

• Analyzes and Audits Claims. • Integrates medical chart coding principles, clinical guidelines and objectivity in performance of medical audit activities. • Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. • Performs work independently. • Effectively Utilizes Audit Tools. • Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters. • Meets or Exceeds Standards/Guidelines for Productivity. • Maintains production goals set by the audit operations management team. • Meets or Exceed Standards/Guidelines for Accuracy and Quality. • Identifies New Claim Types. • Suggests and develops high quality, high value concept and or process improvement, tools, etc.

🎯 Requirements

• Associate or bachelor’s degree in nursing (active /unrestricted license). • Associate or bachelor’s degree in Health Information Management (RHIA or RHIT). • 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. • Coding/CDI Certification (at least one of the following are required): RHIA or RHIT, CPC, Inpatient Coding Credential – CCS, CIC, CDIP or CCDS. • 5 to 7+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology. • Proficiency in Word, Access, Excel, TEAMS, and other applications.

🏖️ Benefits

• Medical, dental, and vision insurance • 401(k) retirement plan • Paid family leave • 9 paid holidays per year • 17-27 days of Paid Time Off (PTO) per year • Discretionary bonus consideration