Auditor, DRG Validation – CMS Audits

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

📋 Description

• Conducts audits on Inpatient DRG Claims: Employs medical chart coding principles alongside client-specific guidelines to execute medical audit activities related to Inpatient DRG claims.

• Works autonomously, examining and interpreting medical records while applying extensive knowledge of coding principles to identify potential billing and coding issues.

• Effectively Utilizes Audit Tools: Demonstrates a high proficiency in using Cotiviti proprietary auditing systems to make audit assessments and produce audit correspondence.

• Meets or Exceeds Productivity Standards/Guidelines: Adheres to production objectives established by the audit operations management team.

• Meets or Exceeds Accuracy and Quality Standards/Guidelines: Achieves the required accuracy and quality levels defined by the audit for valid claim identification and documentation, including letter writing.

⛳️ Requirements

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

• A high school diploma or GED combined with at least 5 years of relevant experience in claims auditing, quality assurance, or recovery auditing is acceptable.

• Certification in Coding/CDI (at least one of the following is mandatory and must be maintained as a condition of employment): RHIA or RHIT, CPC, Inpatient Coding Credential – CCS, CIC, CDIP or CCDS.

• 5 to 7+ years of experience with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG, along with comprehensive knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.

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

• Requires expert knowledge of coding standards - DRG, APR-DRG, ICD-10, CPT, and HCPCS codes.

• Requires familiarity with and adherence to applicable industry-based standards.

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

• Strong written and verbal communication skills are essential.

🏝️ Benefits

• Coverage for medical, dental, vision, disability, and life insurance.

• 401(k) savings plans available.

• Paid family leave provided.

• Nine paid holidays each year.

• Between 17 to 27 days of Paid Time Off (PTO) annually, based on specific level and tenure with Cotiviti.