Auditor, Clinical Validation – Outpatient Specialty

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

📋 Description

• Conduct audits on outpatient and specialty claims, which include APC, PNPP, pharmacy, and/or inpatient DRG claims.

• Carry out coding and clinical chart validation for audits related to outpatient and specialty services.

• Analyze and interpret medical records to pinpoint billing and coding discrepancies.

• Evaluate clinical reviews, coding precision, medical necessity, treatment environments, and services provided.

• Utilize medical chart coding principles along with client-specific guidelines.

• Employ Cotiviti Encoder and various audit tools.

• Accurately input claims into the Cotiviti system.

• Achieve standards for productivity, accuracy, quality, and valid claim identification/documentation.

• Recognize potential claims beyond the designated audit concept where extra recoveries might be achievable.

• Propose and develop audit concepts, process enhancements, tools, and technological advancements.

• Execute strategies and initiatives that bolster audit output, communication, and client satisfaction.

• Analyze information and make logical inferences.

• Fulfill responsibilities outlined in the annual Performance Plan along with special projects or other assigned tasks.

⛳️ Requirements

• An associate or bachelor’s degree in nursing is required.

• An active and unrestricted nursing license is necessary.

• A coding certification that is required and maintained, such as CPC, CIC, CCS, CCS-P, RHIA, or RHIT.

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

• A solid understanding of HIPAA Privacy and Security Rules along with CMS security regulations.

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

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

• Commitment to adhering to official coding guidelines, Coding Clinic determinations, and compliance regulations set by CMS and other authorities.

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

• Strong verbal and written communication skills.

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

• Provision of a dedicated and secure workspace.

• Access to high-speed internet connectivity and the ability to set up and maintain an office environment.

• Capability to perform duties with or without reasonable accommodation.

🏝️ Benefits

• Consideration for discretionary bonuses.

• Medical insurance coverage.

• Dental insurance options.

• Vision insurance available.

• Disability insurance included.

• Life insurance provisions.

• 401(k) savings plan participation.

• Paid family leave benefits.

• 9 paid holidays each year.

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

• Overtime compensation for nonexempt employees for hours worked exceeding 40 per week or as mandated by state law.

• Remote work arrangement flexibility.

• Provision of a dedicated, secure workspace and high-speed internet/office setup by the team member.