Senior Auditor Quality - DRG

Cotiviti

5d•Remote

About The Position

The Sr. Auditor, Quality Assurance position is responsible for ensuring that the audited claims meet quality standards necessary to generate high quality recoverable claims for the benefit of Cotiviti and our clients. Quality assurance emphasizes compliance with established procedures, accuracy of claim identification and supportive documentation. Identifies and notifies management of observed quality and communicates opportunities for process improvements based on independent audit claims review. Displays professional skepticism that enhances the work performed in order to achieve success in position.

Requirements

Associates or Bachelor's degree in Nursing (active / unrestricted license).
Associates or Bachelor's degree 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.
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.
3-5 years of healthcare auditing or related experience.
Ability to mentor staff and enhance performance as it relates to the quality and productivity of auditors.
Excellent verbal and written communication skills.
Ability to work well in an individual and team environment.
Computer proficiency in Microsoft office suite required (Excel, Outlook, PowerPoint, SharePoint,etc.).
Communicating with others to exchange information.
Assessing the accuracy, neatness, and thoroughness of the work assigned.
Remaining in a stationary position, often standing or sitting for prolonged periods.
Repeating motions that may include the wrists, hands, and/or fingers.
Must be able to provide a dedicated, secure work area.
Must be able to provide high-speed internet access/connectivity and office setup and maintenance.

Responsibilities

Performs clinical quality assurance review of daily clinical validation reviews.
Communicates with the initial auditor when there are differing decisions on the audit to ensure that the final decision is supported and as accurate as possible.
Integrates healthcare auditing principles and uses objectivity in performance of medical audit activities and review.
Utilizes industry knowledge and proficiency in healthcare to substantiate decisions.
Performs work independently and reviews work of others.
Depending on nature and scope of audit, may review medical records and apply in-depth knowledge of clinical criteria to determine medical necessity, appropriateness of setting, potential billing/coding issues, and quality concerns.
May serve as a mentor to other QA auditors or initial auditors.
Depending on the business needs, may also flex into the initial audit role and/or the appeals role as needed.