Auditor, Clinical Validation, OPSP Coding
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Job Description
Clinical coding auditor validating outpatient and specialty healthcare claims for Cotiviti. Reviewing medical records, coding accuracy, medical necessity, and billing issues.
Responsibilities:
- Audit outpatient and specialty claims
- Apply medical chart coding principles and client-specific guidelines to outpatient, pharmacy, and/or inpatient DRG claims
- Use advanced coding expertise and industry knowledge to substantiate audit conclusions
- Independently review and interpret medical records to identify billing and coding issues
- Use Cotiviti encoder and audit tools
- Enter claims accurately into the Cotiviti system according to standard procedures
- Meet productivity, accuracy, quality, and production standards
- Identify potential claims outside the assigned audit concept where additional recoveries may be available
- Suggest and develop high-quality, high-value audit concepts, process improvements, and tools
- Apply knowledge of client requirements, contract terms, and complex claim types
- Suggest, develop, and implement ideas, approaches, and technological improvements to enhance audit production, communication, and client satisfaction
- Evaluate information and draw logical conclusions
- Complete responsibilities in the annual Performance Plan
- Complete special projects and other assigned duties
Requirements:
- Associate or bachelor’s degree in Health Information Management (RHIA or RHIT), or equivalent combination of relative work experience
- Coding certification required and maintained, 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/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology
- Ability to become proficient in various outpatient and specialty review types
- Adherence to official coding guidelines, Coding Clinic determinations, and CMS and other regulatory compliance guidelines and mandates
- Expert knowledge of DRG, ICD-10, CPT, and HCPCS codes
- Excellent verbal and written communication skills
- Ability to work independently and in a team environment
- Ability to provide a dedicated, secure work area
- Ability to provide high-speed internet access/connectivity and office setup and maintenance
- Ability to perform duties with or without reasonable accommodation
Benefits:
- Discretionary bonus consideration
- Medical insurance
- Dental insurance
- Vision insurance
- Disability insurance
- Life insurance coverage
- 401(k) savings plan
- 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
- Overtime pay for nonexempt employees for hours worked in excess of 40 hours in a week, or as required by applicable state law
- Remote work arrangement
- Dedicated, secure work area and high-speed internet access/connectivity and office setup and maintenance provided by the employee
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