Cotiviti · 11 hours ago
Auditor Clinical Validation Outpatient Specialty Clinical
United States
Full-time
Remote
Senior Level
$45.67/hr - $45.67/hr
5+ years expCotiviti is a healthcare auditing company seeking an Auditor for Clinical Validation specializing in Outpatient and Specialty audits. The role involves auditing outpatient/specialty claims, ensuring coding accuracy, and documenting audit results while utilizing advanced coding expertise and audit tools.
Responsibilities
Audits Outpatient and Specialty Claims:
Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims
Draws on advanced coding expertise and industry knowledge to substantiate conclusions
Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues
Effectively Utilizes Audit Tools
Utilizes advanced proficiency, Cotiviti encoder and audit tools required to perform duties
Enters claim into Cotiviti system accurately and in accordance with standard procedures
Meets or Exceeds Standards/Guidelines for Productivity Maintains production goals, accuracy and quality standards set by the audit for the auditing concept
Meets Or Exceeds Standards/Guidelines For Quality
A chieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation
Identifies New Claim Types
Identifies potential claims outside of the concept where additional recoveries may be available
Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc
Recommends New Concepts And Processes
Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience
Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction
Evaluates information and draws logical conclusions
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
Required
Associate or bachelor's degree in nursing (active /unrestricted license) AND Certifications/Licenses (required)
Coding Certification required and maintained i.e. CPC, CIC, CCS, CCS-P, RHIA or RHIT
5 to 7 years of experience with clinical medical record coding or auditing and a working knowledge of HIPAA Privacy and Security Rules and CMS security requirements
Working knowledge of HIPAA Privacy and Security Rules, CMS security requirements and clinical medical record coding or auditing
A broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology
Ability and desire to utilize base coding and clinical auditing knowledge to learn and become proficient in a variety of outpatient and specialty review types
Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes
Excellent verbal and written communication skills
Ability to work well in an individual and team environment
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
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
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.
5001-10000 employees
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)
Funding
Current Stage
Late StageLeadership Team
Adam Gilbert
Director, Interoperability Operations and Partnerships
Chris McIntyre
Sr. Program Manager, RQNC Operations
Recent News
2024-04-07
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