Auditor Clinical Validation Outpatient Specialty Clinical

Cotiviti•Remote,

40d•Remote

About The Position

This auditing role focuses on coding and clinical chart validation for outpatient and specialty audits. The role audits outpatient and specialty claims and documents audit results, with an emphasis on clinical review, coding accuracy, medical necessity, appropriateness of treatment setting, and services delivered. The ideal candidate has both nursing and coding/auditing experience focused on disciplines such as SNF, IRF, Home Health, APC, ER, Diagnostics, or Professional Service. The auditor independently reviews and interprets medical records, applies coding principles and client-specific guidelines, and uses Cotiviti encoder and audit tools. The position is expected to meet productivity and quality standards, identify potential claims outside the current audit concept, and contribute ideas and process improvements. The role also requires broad knowledge of clients, contract terms, and complex claim types, along with the ability to evaluate information and draw logical conclusions. The role is scheduled to start on December 7, 2026. It is remote, and the employee must provide a dedicated, secure work area, high-speed internet access, and office setup and maintenance. Base compensation is $45.67 per hour, annualized at $95,000. The role is eligible for discretionary bonus consideration. Nonexempt employees are eligible for overtime pay for hours worked over 40 in a week, or as otherwise required by applicable state law.

Requirements

Associate or bachelor's degree in nursing and an active, unrestricted nursing license.
Maintained coding certification, such as CPC, CIC, CCS, CCS-P, RHIA, or RHIT.
5 to 7 years of experience with clinical medical record coding or auditing.
Working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.
Broad knowledge of medical claims billing and payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
Expert coding knowledge, including DRG, ICD-10, CPT, and HCPCS codes.
Adherence to official coding guidelines, Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
Ability and desire to use coding and clinical auditing knowledge to learn and become proficient in outpatient and specialty review types.
Excellent verbal and written communication skills.
Ability to work effectively both independently and as part of a team.
Ability to communicate with others to exchange information and assess the accuracy, neatness, and thoroughness of assigned work.
Ability to remain stationary, often standing or sitting for prolonged periods, and perform repetitive motions involving the wrists, hands, and/or fingers.
Ability to provide a dedicated, secure work area, high-speed internet access/connectivity, and office setup and maintenance.

Responsibilities

Audit outpatient and specialty claims, including outpatient (APC, PNPP), pharmacy, and/or inpatient DRG claims, using medical chart coding principles and client-specific guidelines.
Review and interpret medical records independently and apply advanced coding expertise to identify potential billing and coding issues.
Use Cotiviti encoder and audit tools proficiently and enter claims into the Cotiviti system accurately and according to standard procedures.
Meet or exceed productivity, accuracy, and quality standards for the applicable auditing concept.
Identify potential claims outside the current audit concept where additional recoveries may be available.
Suggest and develop high-quality, high-value audit concepts, processes, tools, and improvements.
Develop and implement ideas, approaches, and technological improvements that support audit production, communication, and client satisfaction.
Evaluate information and draw logical conclusions.
Complete responsibilities outlined in the annual Performance Plan, special projects, and other assigned duties.
Perform duties with or without reasonable accommodation.