DRG Validation Auditor (Clinical & Coding)

About the role

This auditing role focuses on Coding & Clinical Chart Validation for our Inpatient audits (DRG Validation). The ideal candidate must have both a clinical (nurse) and coding / auditing background, specifically in Inpatient DRG/APR-DRG.

Responsibilities

• Analyzes and Audits Claims
• Integrates medical chart coding principles, clinical guidelines and objectivity in performance of medical audit activities
• Drafs conclusions based on advanced ICD-10 coding expertise, clinical guidelines, and industry knowledge
• 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 and suggests and develops high quality, high value concept and or process improvement, tools, etc.
• Completes all responsibilities as outlined on annual Performance Plan
• Completes all special projects and other duties as assigned

Qualifications

• Education: Associate or bachelor’s degree in nursing (active /unrestricted license), Associate or bachelor’s degree Health Information Management (RHIA or RHIT), High school diploma or GED plus equivalent experience of 5+ years’ experience 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

Benefits

• Base compensation is paid hourly at $45.67 per hour (95k annualized)
• Eligible for discretionary bonus consideration
• Competitive benefits package including medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti