Auditor, Clinical Validation, Outpatient Specialty

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

📋 Description

• Conducts audits of Outpatient and Specialty Claims: Employs medical chart coding principles along with client-specific guidelines to carry out medical audit activities involving Outpatient (APC, PNPP), Pharmacy, and/or Inpatient DRG claims.

• Leverages advanced coding expertise and industry insights to support conclusions.

• Operates independently to review and analyze medical records, applying detailed knowledge of coding principles to identify potential billing and coding discrepancies.

• Effectively Utilizes Audit Tools: Demonstrates advanced proficiency with Cotiviti encoder and other necessary audit tools to execute responsibilities.

• Meets or Exceeds Standards/Guidelines for Quality: Achieves the quality levels expected by the audit for valid claim identification and documentation.

• Identifies New Claim Types: Recognizes potential claims outside of the established concept where additional recoveries might be feasible.

• Recommends New Concepts and Processes: Possesses extensive knowledge of client, contract terms, and complex claim types acquired through significant healthcare auditing experience.

• Proposes, develops, and implements innovative ideas, approaches, or technological enhancements that will boost audit production, communication, and client satisfaction.

⛳️ Requirements

• Associate or bachelor’s degree in nursing (active/unrestricted license).

• Coding Certification 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.

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

• Extensive understanding of medical claims billing/payment systems and provider billing guidelines.

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

• Requires expert-level coding knowledge in DRG, ICD-10, CPT, and HCPCS codes.

• Exceptional verbal and written communication skills.

• Ability to thrive in both individual and team settings.

🏝️ Benefits

• Medical, dental, vision, disability, and life insurance coverage.

• 401(k) savings plans.

• Paid family leave.

• 9 paid holidays each year.

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