Associate Auditor Clinical Validation DRG

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
• This review may include medical record review and/or episode of care reviews
• Performs work independently
• Utilizes Cotiviti proprietary auditing systems with a high level of proficiency to make audit determinations and generate audit letters
• Maintains production goals set by the audit operations management team
• 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
• Suggests and develops high quality, high value concept and or process improvement, tools, etc.

Qualifications

• Education: Associate or bachelor’s degree in nursing (active /unrestricted license), Associate or bachelor’s degree Health Information Management (RHIA or RHIT), Licensed Practical Nurse (LPN) (active /unrestricted license)
• Coding/CDI Certification: RHIA or RHIT, CPC or COC, Inpatient Coding Credential – CCS, CIC, CDIP or CCDS
• Experience: 2 years of prior clinical and/or coding experience preferred
• Basic to Intermediate knowledge of medical and coding terminology, Working knowledge of medical claims billing/payment systems and provider billing guidelines preferred
• Requires working knowledge of and applicable industry-based standards, Proficiency in Word, Access, Excel, TEAMS, and other applications
• Excellent written and verbal communication skills