Auditor Clinical Validation – Place of Service, Short Stay, Readmission

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

📋 Description

• Conduct retrospective reviews of clinical charts for Readmission and Place of Service Claims.

• Apply nationally recognized guidelines, clinical review judgment, and review methodologies specific to contracts.

• Use proprietary systems to audit medical records effectively.

• Employ critical thinking and decision-making abilities to reach audit conclusions.

• Precisely document rationales, findings, and supporting references.

• Analyze and audit claims by correlating the severity of illness and the intensity of service outlined in medical charts.

• Utilize Cotiviti’s proprietary auditing systems and prepare audit letters.

• Achieve productivity targets established by audit operations management.

• Adhere to accuracy and quality benchmarks for valid claim identification and documentation.

• Recognize potential claims outside the audit scope where additional recoveries could be pursued.

• Recommend and develop opportunities for process improvement and tool enhancement.

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

⛳️ Requirements

• Associate or Bachelor's degree in nursing.

• Active, unrestricted RN License in the state of residence.

• 5 to 7+ years of experience with InterQual/MCG (Inpatient vs Observation).

• Background in Utilization Management and/or Case Management.

• Experience in Critical Care settings: ICU, Emergency Room, Cath Lab, Med Surg.

• Familiarity with applicable industry standards.

• Proficient in Word, Access, Excel, TEAMS, and other relevant applications.

• Exceptional written and verbal communication abilities.

• Capability to provide a dedicated and secure work environment.

• Ability to ensure high-speed internet access/connectivity, along with office setup and maintenance.

• Competence to perform duties with or without reasonable accommodation.

🏝️ Benefits

• Consideration for discretionary bonuses.

• Overtime compensation for hours worked beyond 40 hours per week, or as mandated by applicable state law.

• 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 annually.

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