Auditor Clinical Validation (Place of Service, Short Stay & Readmission)

This auditing role will be responsible for performing retrospective clinical chart reviews on Readmission and Place of Service Claims by utilizing nationally accepted guidelines, clinical review judgment, and review methodologies specific to the contract for which services are provided.

Responsibilities

• Analyzes and audits claims by integrating medical chart severity of illness and intensity of service based on clinical guidelines and objectivity in performance of medical audit activities.
• Effectively 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, accuracy, and quality as set by audit operations management.
• Identifies potential claims outside of the concept where additional recoveries may be available.
• Suggests and develops high-quality, high-value concepts and/or process improvements, tools, etc.
• Completes all responsibilities outlined on the annual Performance Plan, special projects, and other duties as assigned.
• Performs duties with or without reasonable accommodation.

Requirements

• Associate or Bachelor’s degree in nursing.
• Active/unrestricted RN License in state of residence.
• 5 to 7+ years of experience with InterQual/MCG (Inpatient vs Observation).
• Experience in Utilization Management and/or Case Management.
• Critical Care background: ICU, Emergency Room, Cath Lab, Med Surg.
• Working knowledge of applicable industry-based standards.
• Proficiency in Word, Access, Excel, TEAMS, and other applications.
• Excellent written and verbal communication skills.

Case Management Certification is preferred.

Mental Requirements

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

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.

Schedule

Training will be from October 5, 2026, through mid-November, with a daytime schedule of 9 AM – 5:30 PM ET. No time off will be allowed during this period.

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 are eligible for overtime pay for hours worked in excess of 40 hours per week.

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.