Auditor Clinical Validation DRG

Cotiviti

120d • $45

About The Position

This auditing role will focus on Coding & Clinical Chart Validation for our Inpatient audits. The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on the following disciplines from a coding and billing perspective: Inpatient DRG/APR-DRG. This position is responsible for auditing inpatient claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, and the appropriateness of treatment setting and services delivered.

Requirements

• Education (at least one of the following are required): Associate or bachelor’s degree in nursing (active /unrestricted license).
• Associate or bachelor’s degree Health Information Management (RHIA or RHIT).
• High school diploma or GED plus 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/CDI Certification (at least one of the following are required and are to be maintained as a condition of employment): RHIA or RHIT, CPC, Inpatient Coding Credential – CCS, CIC, CDIP or CCDS.
• 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, APRDRG, ICD-10, CPT, HCPCS codes.
• Requires working knowledge of and applicable industry-based standards.
• Proficiency in Word, Access, Excel, TEAMS, and other applications.
• Excellent written and verbal communication skills.

Responsibilities

• Analyzes and Audits Claims. Integrates medical chart coding principles, clinical guidelines and objectivity in 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 concept and or process improvement, tools, etc.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

Benefits

• Medical, dental, vision, disability, and life insurance coverage.
• 401(k) savings plans.
• Paid family leave.
• 9 paid holidays per year.
• 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.

What This Job Offers

• Career Level: Senior
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees