Auditor DRG Validation (CMS Audits)

Responsibilities

• Audits Inpatient DRG Claims: Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Inpatient DRG claims.
• Draws on advanced clinical 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 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. 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.

Qualifications

• Education: Associate or bachelor’s degree in Health Information Management (RHIA or RHIT), or equivalent experience of 5+ years in claims auditing, quality assurance, or recovery auditing.
• Coding/CDI Certification: RHIA or RHIT, CPC, Inpatient Coding Credential – CCS, CIC, CDIP or CCDS.
• Experience: 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.
• Proficiency in Word, Access, Excel, TEAMS, and other applications.
• Excellent written and verbal communication skills.