Auditor, DRG Validation – CMS Audits
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Job Description
Healthcare auditor validating inpatient DRG coding and claims for Cotiviti. Reviewing medical records, identifying billing issues, and documenting audit recoveries.
Responsibilities:
- Audit inpatient DRG claims using medical chart coding principles and client-specific guidelines
- Review and interpret medical records independently
- Apply in-depth coding knowledge to determine potential billing and coding issues
- Draw on advanced clinical expertise and industry knowledge to substantiate conclusions
- Use Cotiviti proprietary auditing systems to make audit determinations and generate audit letters
- Meet productivity goals established by audit operations management
- Meet accuracy and quality standards for valid claim identification and documentation
- Identify potential claims outside the audit concept where additional recoveries may be available
- Suggest and develop high-quality, high-value concepts, process improvements, and tools
- Complete annual performance plan responsibilities
- Complete special projects and other assigned duties
Requirements:
- Associate or bachelor’s degree in Health Information Management (RHIA or RHIT)
- Alternatively, high school diploma or GED plus equivalent experience of 5+ years in claims auditing, quality assurance, or recovery auditing, ideally in a DRG / Clinical Validation Audit setting or a hospital environment
- At least one required and maintained certification: RHIA, RHIT, CPC, CCS, CIC, CDIP, or CCDS
- 5 to 7+ years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG
- 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
- Expert knowledge of DRG, APRDRG, ICD-10, CPT, and HCPCS codes
- Working knowledge of applicable industry-based standards
- Proficiency in Word, Access, Excel, TEAMS, and other applications
- Excellent written and verbal communication skills
- Ability to communicate with others to exchange information
- Ability to assess the accuracy, neatness, and thoroughness of assigned work
- 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 coverage
- Dental insurance coverage
- Vision insurance coverage
- Disability insurance coverage
- 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
- Overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law
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