DRG Validation Auditor – Off Hours Work

🔥 4 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 for prepay and retrospective audits • Perform DRG Validation and make determinations without a medical record • Conduct clinical review focused on coding accuracy, treatment setting, services delivered, and patient history • Integrate medical chart coding principles, clinical guidelines, and objectivity into medical audit activities • Use advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions • Utilize Cotiviti proprietary auditing systems to make audit determinations and generate audit letters • Maintain productivity goals set by audit operations management • Meet accuracy and quality standards for valid claim identification and documentation, including letter writing • 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 and special projects or other assigned duties

🎯 Requirements

• Associate or bachelor’s degree in nursing with an active/unrestricted license • Associate or bachelor’s degree in Health Information Management with 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 • At least one required coding/CDI certification, maintained as a condition of employment: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS • 5 to 7+ years 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, 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 work independently • Ability to work off-hour shifts from 3 PM-11 PM or 11 PM-7 AM ET, including weekends and holidays • 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 with Cotiviti • Overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law • Remote work arrangement • Dedicated, secure work area and high-speed internet access/connectivity and office setup and maintenance provided by the candidate