Auditor, Clinical Validation, DRG

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct audits of inpatient claims, emphasizing coding and clinical chart validation.

• Record audit findings and assess clinical reviews, coding accuracy, treatment settings, and services provided.

• Utilize medical chart coding principles, clinical guidelines, advanced ICD-10 coding expertise, and industry knowledge to support audit conclusions.

• Work independently to complete tasks.

• Employ Cotiviti proprietary auditing systems to make audit decisions and create audit letters.

• Achieve productivity targets set by audit operations management.

• Adhere to accuracy and quality standards for valid claim identification and documentation, including letter writing.

• Recognize new claim types and potential claims outside the audit framework where additional recoveries might be accessible.

• Propose and develop high-quality, high-value concepts, process enhancements, and tools.

• Fulfill annual Performance Plan responsibilities, special projects, and other assigned tasks.

⛳️ Requirements

• An associate or bachelor’s degree in nursing with an active/unrestricted license; or an associate or bachelor’s degree in Health Information Management with RHIA or RHIT; or a high school diploma/GED plus a minimum of 5 years’ equivalent experience in claims auditing, quality assurance, or recovery auditing.

• A minimum of one coding/CDI certification is required and must be maintained: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS.

• 5 to 7+ years of experience with ICD-9/10-CM, MS-DRG, AP-DRG, and APR-DRG.

• Extensive knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.

• Compliance with official coding guidelines, Coding Clinic determinations, CMS, and other regulatory compliance guidelines and mandates.

• In-depth knowledge of DRG, APR-DRG, ICD-10, CPT, and HCPCS codes.

• Familiarity with relevant industry-based standards.

• Proficiency in Word, Access, Excel, Teams, and other applications.

• Exceptional written and verbal communication skills.

• Capability to perform tasks with or without reasonable accommodation.

• Ability to provide a dedicated, secure work area, high-speed internet connectivity, and office setup/maintenance.

• Capacity to remain stationary, often standing or sitting for extended periods, and perform repetitive 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.