Auditor Clinical Validation DRG

This auditing role focuses on Coding & Clinical Chart Validation for Inpatient audits. The ideal candidate has both a clinical (nurse) and a coding/auditing background with expertise in Inpatient DRG/APR-DRG from coding and billing perspectives.

Responsibilities

• Analyze and audit inpatient claims, documenting results with a focus on clinical review, coding accuracy, and appropriateness of treatment setting and services delivered.
• Integrate medical chart coding principles, clinical guidelines, and objectivity in audit activities.
• Apply advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge to substantiate audit conclusions.
• Perform work independently.
• Utilize Cotiviti proprietary auditing systems proficiently to make audit determinations and generate audit letters.
• Maintain production goals set by audit operations management.
• Achieve expected levels of accuracy and quality for valid claim identification and documentation (letter writing).
• Identify potential claims outside the concept where additional recoveries may be available.
• Suggest and develop high-quality, high-value concepts, process improvements, or tools.
• Complete all responsibilities outlined in the annual Performance Plan.
• Complete special projects and other duties as assigned.
• Perform duties with or without reasonable accommodation.

Requirements

• 5 to 7+ years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG, including 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.
• Expert coding knowledge of DRG, APR-DRG, ICD-10, CPT, and HCPCS codes.
• Working knowledge of applicable industry-based standards.
• Proficiency in Microsoft Word, Access, Excel, Teams, and other applications.
• Excellent written and verbal communication skills.

Qualifications

Education (at least one of the following required):

• Associate or bachelor’s degree in nursing (active/unrestricted license).
• Associate or bachelor’s degree in Health Information Management (RHIA or RHIT).
• High school diploma or GED plus 5+ years of experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG/Clinical Validation Audit setting or hospital environment.

Coding/CDI Certification (at least one of the following required and must be maintained as a condition of employment):

• RHIA or RHIT.
• CPC.
• Inpatient Coding Credential – CCS, CIC, CDIP, or CCDS.

Mental Requirements

• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of assigned work.

Physical Requirements and Working Conditions

• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• Must provide a dedicated, secure work area with high-speed internet access/connectivity and office setup/maintenance.
• No adverse environmental conditions expected.

Pay

Base compensation is paid hourly at $45.67 per hour (annualized at $95,000). This role is eligible for discretionary bonus consideration. Nonexempt employees receive overtime pay for hours worked in excess of 40 hours per week, or as required by applicable state law.

Benefits

• Medical, dental, vision, disability, and 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 level and length of service.