[Remote] DRG Validation Auditor (Clinical & Coding)

Note: The job is a remote job and is open to candidates in USA. Cotiviti is a healthcare auditing company, and they are seeking a DRG Validation Auditor to focus on Coding & Clinical Chart Validation for inpatient audits. The role involves auditing inpatient claims, ensuring coding accuracy, and documenting audit results while utilizing proprietary auditing systems.

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

Skills

• 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
• RHIA or RHIT certification
• CPC certification
• 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
• 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
• No adverse environmental conditions expected

Benefits

• Medical
• Dental
• Vision
• Disability
• 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.

Company Overview

Company H1B Sponsorship