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Cotiviti · 1 day ago

Auditor Clinical Validation DRG

United States

Full-time

Remote

Senior Level

$45.67/hr - $45.67/hr

5+ years exp

Cotiviti is a healthcare analytics company that provides insights and solutions to improve patient outcomes and reduce costs. They are seeking an Auditor Clinical Validation DRG who will focus on auditing inpatient claims, ensuring coding accuracy, and validating clinical charts. The role involves analyzing claims, utilizing auditing tools, and meeting productivity and quality standards.

Information Technology & Services

H1B Sponsor Likely

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

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

Qualification

ICD-10 codingDRG/APR-DRG knowledgeClaims auditingRHIARHITCPC certificationCCSCICCDIPCCDSMedical claims billingMicrosoft Office proficiencyCommunication skills

Required

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

CPC

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

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

Cotiviti

Glassdoor3.7

Cotiviti enables healthcare organizations to deliver better care at lower cost through advanced technology and data analytics that improve the quality and sustainability of healthcare in the United States.

Founded in 1979

South Jordan, UT, US

5001-10000 employees

http://www.cotiviti.com

H1B Sponsorship

Cotiviti has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (165)

2024 (118)

2023 (90)

2022 (102)

2021 (72)

2020 (67)