DRG Validation Auditor – Off Hours Work

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

📋 Description

• Conduct audits on inpatient claims for both prepay and retrospective reviews.

• Execute DRG validation and make determinations without relying on a medical record.

• Perform clinical reviews that focus on coding accuracy, treatment settings, services rendered, and patient history.

• Incorporate medical chart coding principles, clinical guidelines, and objective analysis into medical audit activities.

• Apply advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to support conclusions.

• Utilize Cotiviti's proprietary auditing systems to reach audit determinations and produce audit letters.

• Adhere to productivity targets established by audit operations management.

• Comply with accuracy and quality standards for valid claim identification and documentation, which includes letter writing.

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

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

• Fulfill annual Performance Plan responsibilities and complete special projects or other assigned tasks.

⛳️ Requirements

• An associate or bachelor’s degree in nursing with an active and unrestricted license.

• An associate or bachelor’s degree in Health Information Management with RHIA or RHIT credentials.

• High school diploma or GED accompanied by at least 5 years of equivalent experience in claims auditing, quality assurance, or recovery auditing, preferably in a DRG/Clinical Validation Audit context or hospital environment.

• One mandatory coding/CDI certification, maintained as a condition of employment: 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 criteria, and coding terminology.

• Commitment to official coding guidelines, coding clinic determinations, CMS, and other regulatory compliance requirements.

• Expert knowledge of DRG, APRDRG, ICD-10, CPT, and HCPCS codes.

• Familiarity with relevant industry-based standards.

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

• Strong written and verbal communication skills.

• Capability to work independently.

• Willingness to work off-hour shifts from 3 PM-11 PM or 11 PM-7 AM ET, including weekends and holidays.

• Ability to ensure a dedicated and secure work environment.

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

• Ability to perform responsibilities with or without reasonable accommodation.

🏝️ Benefits

• Discretionary bonus consideration.

• 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 each year.

• 17-27 days of Paid Time Off (PTO) annually, based on specific level and duration of service with Cotiviti.

• Overtime compensation for hours exceeding 40 in a week, or as mandated by applicable state law.

• Remote work arrangement.

• Provision for a dedicated, secure work area, along with high-speed internet access/connectivity and office setup and maintenance by the candidate.