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 related to Readmission and Place of Service claims.

• Utilize proprietary systems to audit medical records effectively.

• Employ nationally recognized guidelines, clinical judgment, and specific methodologies for contract reviews.

• Record audit rationales, findings, and references that support the review process.

• Analyze claims while considering the severity of illness and the intensity of services documented in medical charts.

• Leverage Cotiviti's proprietary auditing systems to make determinations and produce audit letters.

• Adhere to production targets set by audit operations management.

• Achieve necessary accuracy and quality standards for claim identification and documentation.

• Identify potential claims that fall outside the typical audit scope where additional recoveries could be pursued.

• Propose and develop initiatives for concepts, process improvements, and tools.

• Fulfill responsibilities outlined in the annual Performance Plan and complete assigned special projects.

⛳️ Requirements

• An Associate or Bachelor's degree in nursing is required.

• Must possess an active, unrestricted RN license in the state of residence.

• A minimum of 5 to 7+ years of experience with InterQual/MCG for Inpatient versus Observation reviews is essential.

• Experience in Utilization Management and/or Case Management is preferred.

• A background in Critical Care, including ICU, Emergency Room, Cath Lab, or Med Surg, is advantageous.

• Familiarity with relevant industry standards is necessary.

• Proficiency in Word, Access, Excel, TEAMS, and other applications is required.

• Strong written and verbal communication skills are essential.

• Must be able to provide a secure, dedicated work area.

• High-speed internet access/connectivity and a proper office setup and maintenance are necessary.

• Ability to perform job functions with or without reasonable accommodation is required.

🏝️ Benefits

• Consideration for discretionary bonuses.

• Comprehensive medical insurance coverage.

• Dental insurance coverage provided.

• Vision insurance coverage available.

• Disability insurance coverage offered.

• Life insurance coverage included.

• Access to 401(k) savings plans.

• Paid family leave benefits.

• 9 paid holidays are provided each year.

• Earn between 17 to 27 days of Paid Time Off (PTO) annually, depending on level and length of service.