Auditor, DRG Validation – CMS Audits

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

📋 Description

• Conduct audits of inpatient DRG claims following medical chart coding standards and client-specific protocols.

• Independently analyze and interpret medical records.

• Utilize extensive coding expertise to identify potential billing and coding discrepancies.

• Leverage advanced clinical knowledge and industry insights to support conclusions.

• Employ Cotiviti's proprietary auditing tools to make audit decisions and produce audit letters.

• Achieve productivity targets set by the audit operations management team.

• Maintain accuracy and quality benchmarks for valid claim identification and documentation.

• Recognize potential claims beyond the audit scope where additional recoveries may be attainable.

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

• Fulfill annual performance plan objectives.

• Undertake special projects and other assigned responsibilities.

⛳️ Requirements

• An associate or bachelor’s degree in Health Information Management (RHIA or RHIT).

• Alternatively, a high school diploma or GED combined with at least 5 years of relevant experience in claims auditing, quality assurance, or recovery auditing, preferably in a DRG/Clinical Validation Audit context or hospital environment.

• At least one required and maintained certification: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS.

• 5 to 7+ years of experience with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG.

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

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

• Expert level knowledge of DRG, APRDRG, ICD-10, CPT, and HCPCS coding systems.

• Working knowledge of relevant industry standards.

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

• Strong written and verbal communication abilities.

• Capacity to communicate effectively to share information.

• Skill in evaluating the accuracy, neatness, and thoroughness of assigned tasks.

• Ability to provide a dedicated, secure workspace.

• Capability to ensure high-speed internet access/connectivity and maintain an office setup.

• Competence to perform duties with or without reasonable accommodations.

🏝️ Benefits

• Discretionary bonus eligibility.

• Coverage for medical insurance.

• Coverage for dental insurance.

• Coverage for vision insurance.

• Coverage for disability insurance.

• Coverage for life insurance.

• 401(k) retirement savings plan.

• Paid family leave.

• 9 paid holidays each year.

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

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