Auditor, Clinical Validation, OPSP Coding

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

📋 Description

• Conduct audits on outpatient and specialty claims.

• Implement medical chart coding principles alongside client-specific guidelines for outpatient, pharmacy, and/or inpatient DRG claims.

• Leverage advanced coding expertise and industry knowledge to support audit findings.

• Perform independent reviews and interpretations of medical records to pinpoint billing and coding discrepancies.

• Utilize Cotiviti encoder and audit tools effectively.

• Accurately input claims into the Cotiviti system following established procedures.

• Achieve productivity, accuracy, quality, and production benchmarks.

• Identify potential claims beyond the assigned audit scope where additional recoveries might be possible.

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

• Apply knowledge of client obligations, contract specifications, and complex claim categories.

• Recommend, design, and implement innovative ideas, strategies, and technological advancements to improve audit output, communication, and client satisfaction.

• Assess information and draw logical conclusions.

• Fulfill responsibilities outlined in the annual Performance Plan.

• Execute special projects and other tasks as assigned.

⛳️ Requirements

• Associate or bachelor’s degree in Health Information Management (RHIA or RHIT), or a comparable combination of relevant work experience.

• Coding certification is required and must be maintained, such as CPC, CIC, CCS, CCS-P, RHIA, or RHIT.

• 5 to 7 years of experience in clinical medical record coding or auditing.

• Familiarity with HIPAA Privacy and Security Rules and CMS security requirements.

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

• Capability to achieve proficiency in various outpatient and specialty review types.

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

• Expert-level knowledge of DRG, ICD-10, CPT, and HCPCS codes.

• Strong verbal and written communication skills.

• Ability to work independently as well as collaboratively in a team setting.

• Provision of a dedicated, secure workspace.

• Availability of high-speed internet access/connectivity and office setup and maintenance.

• Capability to perform duties with or without reasonable accommodation.

🏝️ Benefits

• Consideration for discretionary bonuses.

• Medical insurance coverage.

• Dental insurance options.

• Vision insurance benefits.

• Disability insurance provisions.

• Life insurance coverage.

• 401(k) savings plan availability.

• Paid family leave benefits.

• 9 paid holidays annually.

• 17–27 days of Paid Time Off (PTO) per year, based on specific level and length of service.

• Overtime compensation for nonexempt employees for hours worked beyond 40 hours in a week, or as mandated by applicable state law.

• Opportunity for remote work arrangements.

• Provision of a dedicated, secure workspace and high-speed internet access/connectivity, with office setup and maintenance handled by the employee.