Senior Auditor Quality - OPSP

Cotiviti•Remote,

7d•$47 - $56•Remote

About The Position

The Senior Auditor, Quality Assurance is responsible for ensuring audited claims meet quality standards and produce high-quality recoverable claims for Cotiviti and its clients. Audited claim types include outpatient and specialty reviews such as SNF, IRF, HH, DME, hospice, and medical necessity. Quality assurance focuses on compliance with established procedures, accurate claim identification, and supporting documentation. The role identifies and reports quality observations to management and communicates process-improvement opportunities based on independent claim audits. Professional skepticism is expected to enhance audit work and support success in the position. The role performs clinical quality assurance reviews of daily clinical validation reviews, resolving differing decisions with initial auditors so final decisions are accurate and supported. Depending on audit scope, the auditor may review medical records and apply clinical criteria to assess medical necessity, appropriateness of setting, potential billing or coding issues, and quality concerns. The position works independently, reviews the work of others, and may mentor QA or initial auditors. Based on business needs, the role may also support initial auditing or appeals. This job description describes the general nature and level of work and is not an exhaustive list of duties. It does not constitute an employment agreement and may change with business needs and job requirements.

Requirements

Associate or bachelor's degree in Nursing and an active, unrestricted nursing license, or equivalent experience of 5+ years in claims auditing, quality assurance, or recovery auditing; clinical validation auditing or a hospital environment is ideal.
At least one coding certification must be held and maintained as a condition of employment: RHIA or RHIT.
Three to five years of healthcare auditing or related experience.
Ability to mentor staff and improve auditor quality and productivity.
Excellent verbal and written communication skills.
Ability to work effectively independently and as part of a team.
Proficiency with Microsoft Office, including Excel, Outlook, PowerPoint, and SharePoint.

Nice To Haves

Inpatient coding credential such as CCS or CIC is preferred.
Candidates with CCDS or CPC will be considered but must obtain an inpatient coding certification within one year of hire.

Responsibilities

Perform clinical quality assurance reviews of daily clinical validation reviews.
Communicate with initial auditors when audit decisions differ to ensure the final decision is accurate and supported.
Apply healthcare auditing principles and objectivity in medical audit activities and reviews.
Use healthcare industry knowledge and proficiency to substantiate decisions.
Work independently and review the work of others.
As appropriate to the audit, review medical records and apply clinical criteria to assess medical necessity, appropriateness of setting, potential billing or coding issues, and quality concerns.
May mentor QA auditors or initial auditors.
May flex into initial audit or appeals work as business needs require.
Identify and notify management of observed quality issues and communicate process-improvement opportunities.

Benefits

Medical insurance
Dental insurance
Vision insurance
Disability insurance
Life insurance
401(k) savings plan
Paid family leave
9 paid holidays per year
17–27 days of paid time off per year, depending on level and length of service
Discretionary bonus consideration
Overtime pay for nonexempt employees for hours worked in excess of 40 per week, or as required by applicable state law