Senior Auditor, Appeals

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

📋 Description

• Advocate for Cotiviti's recovery decisions and manage appeals for SNF, IRF, home health, DME, and hospice claims.

• Evaluate appealed outpatient and specialty claims by applying medical chart coding principles, client-specific guidelines, and appeals protocols.

• Analyze initial claims along with associated documents and additional appeal information submitted by providers.

• Interpret medical records and utilize coding principles, medical necessity criteria, and appeals regulations to make informed determinations.

• Develop factual, well-referenced, grammatically correct, and claim-specific appeal responses for providers.

• Utilize Cotiviti encoder and audit tools while accurately entering appeal claims into Cotiviti systems.

• Uphold production, accuracy, quality, productivity, and service-level standards.

• Provide constructive educational feedback to initial audit teams and QA based on appeal outcomes.

• Propose and execute enhancements in appeals concepts, processes, and technologies.

• Investigate disputes related to MAC determinations, LCDs, NCDs, and MAC-specific billing/documentation criteria.

• Analyze MAC guidance against CMS manuals, regulations, and Cotiviti policies to identify inconsistencies or gaps.

• Compile organized findings, supporting documentation, escalations, and communications with MACs, payers, and clients.

• Monitor MAC decisions and trends, flagging recurring issues for leadership attention.

• Assist with cases progressing to the Administrative Law Judge level of appeal.

• Create case summaries, clinical timelines, position papers, medical record excerpts, policy citations, and hearing exhibits.

• Identify strengths and weaknesses of cases, anticipate provider arguments, and prepare counterarguments.

• Support legal, compliance, or hearing personnel with research, fact-checking, and clinical/coding rationale.

• Participate in hearing preparation, including pre-hearing discussions and serving as a clinical and coding resource.

• Adapt to QA auditor or initial auditor roles as required by business needs.

• Complete designated special projects and additional responsibilities.

⛳️ Requirements

• Associate's or Bachelor's degree in Nursing.

• Active/unrestricted nursing license.

• Outpatient Coding Credential is mandatory and must be maintained as a condition of employment: CCS, CCS-P, or CPC.

• Nurses without coding certification may be eligible if they can sit for the credential but must acquire it within the first six months of employment.

• Over five years of relevant healthcare experience, particularly with auditing SNF, IRF, Home Health, DME, and Hospice claims.

• Preferred two years of experience as a Cotiviti Auditor Clinical Validation.

• Familiarity with appeals processes, defending audit determinations, and communicating with providers.

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

• Expert understanding of official coding guidelines, Coding Clinic determinations, and CMS and other regulatory compliance mandates.

• Proficient knowledge of Medicare coverage policies, medical necessity guidelines, appeals regulations, and relevant industry standards.

• Skilled in Word, Access, Excel, and various business applications.

• Exceptional written and verbal communication abilities.

• Capacity to construct clear, factual, and well-supported written responses and communications.

• Proficient use of AI to enhance efficiency and quality while independently validating all content.

• Ability to work autonomously as well as in collaborative team settings.

• Must have high-speed internet access/connectivity and maintain an appropriate office setup.

• Requirement for a dedicated, secure workspace.

• Must reside and work within the continental United States.

• Flexibility and willingness to engage in processes of an international organization, including calls across global time zones.

• Must be able to fulfill job responsibilities with or without reasonable accommodation.

🏝️ Benefits

• Discretionary bonus eligibility.

• Overtime pay for nonexempt employees for hours worked exceeding 40 per week, or as mandated by state law.

• Medical insurance coverage.

• Dental insurance coverage.

• Vision insurance coverage.

• Disability insurance.

• Life insurance.

• 401(k) savings plan.

• Paid family leave.

• Nine paid holidays annually.

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

• Work-from-home arrangement.

• Requirement for high-speed internet access/connectivity and appropriate office setup for remote work.

• Dedicated, secure work area mandatory.