The Auditor, DRG Coding & Clinical Validation position has an extensive background in either facility-based nursing, clinical documentation, and/or inpatient coding and has a high level of understanding in reimbursement guidelines specifically an understanding of the MS-DRG, AP-DRG and APR-DRG payment systems. This position is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of Cotiviti and our clients. Responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy.

Analyzes and Audits Claims. Integrates medical chart coding principles, clinical guidelines, and objectivity in the performance of medical audit activities. Draws on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate conclusions. Performs work independently.

• Effectively Utilizes Audit Tools. Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters.

• Meets or Exceeds Standards/Guidelines for Productivity. Maintains production goals set by the audit operations management team.

• Meets or Exceed Standards/Guidelines for Accuracy and Quality. Achieves the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation (letter writing).

• Identifies New Claim Types. Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high-quality, high-value concepts and or process improvement, tools, etc.

• Education (at least one of the following is required)-
  • Associates or Bachelor's degree in Nursing (active/unrestricted license)
  • Associate or Bachelor's degree in Health Information Management (RHIA or RHIT)
  • Equivalent experience of 5+ years experience in claims auditing, quality assurance, or recovery auditing...ideally in a DRG / Clinical Validation Audit setting or a hospital environment.
• Coding Certification (at least one of the following are required and are to be maintained as a condition of employment)
  • RHIA or RHIT
  • Inpatient Coding Credential - CCS or CIC preferred
  • Candidates who hold a CCDS or CPC will be given consideration but will need to obtain an inpatient coding certification within 1 year of their hire date with the company.
• Experience (required)
  • 5 to 7+ years of working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
  • Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG & ICD-10.
  • Requires working knowledge of applicable industry-based standards.
  • Proficiency in Word, Access, Excel, and other applications.
  • Excellent written and verbal communication skills.

Work Environment:

• This is an at home-based position and you must have a work location within the continental US
• This position requires that you provide a high-speed internet connection and a work environment free from distractions (all other equipment will be provided by the company).
• This role is aligned to certain productivity and quality requirements
• Must be able to sit and use a computer keyboard for extended periods of time
• Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones.

Base compensation is paid hourly at $44.23/hour (92k annualized). This role is eligible for discretionary bonus consideration.

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti. For information about our benefits package, please refer to our Careers page.

Date of posting: 2/19/2023

Applications are assessed on a rolling basis. We anticipate that the application window will close on 4/19/2024, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

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