DRG Validation Auditor, Clinical & Coding

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

📋 Description

• Conducts analysis and audits of claims.

• Incorporates medical chart coding principles, clinical guidelines, and objectivity into the execution of medical audit tasks.

• Utilizes advanced ICD-10 coding knowledge, clinical guidelines, and industry insights to support findings.

• Works autonomously.

• Effectively employs audit tools.

• Demonstrates a high level of proficiency in using Cotiviti proprietary auditing systems to make audit decisions and produce audit letters.

• Achieves or surpasses productivity standards and guidelines.

• Adheres to production targets established by the audit operations management team.

• Meets or exceeds accuracy and quality standards and guidelines.

• Identifies new types of claims.

• Proposes and develops high-quality, value-added concepts and process improvements, tools, etc.

⛳️ Requirements

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

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

• A high school diploma or GED along with a minimum of 5 years of relevant experience in claims auditing, quality assurance, or recovery auditing, preferably in a DRG/Clinical Validation Audit context or a hospital setting.

• Coding/CDI Certification (at least one of the following is required): 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.

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

🏝️ Benefits

• Medical, dental, and vision insurance.

• 401(k) retirement plan.

• Paid family leave.

• 9 paid holidays per year.

• 17-27 days of Paid Time Off (PTO) annually.

• Discretionary bonus consideration.