Auditor Clinical Validation DRG

Cotiviti; United States; Remote; USD 45,000 - 100,000; Full time

Job summary

A leading company in healthcare auditing is seeking a Clinical Auditor focusing on Coding & Clinical Chart Validation. The role requires strong expertise in ICD-10 coding and auditing inpatient claims, ensuring coding accuracy and compliance with healthcare standards. Applicants should have clinical nursing qualifications and relevant coding certifications, contributing to a dynamic team committed to improving patient care and claims processing efficiency.

Benefits

Medical insurance

Dental insurance

Vision insurance

401(k) savings plan

Paid Time Off (PTO)

Paid family leave

Discretionary bonus eligibility

Qualifications

• 5 to 7+ years of experience with ICD-9/10CM coding.
• Expert coding knowledge of DRG, APRDRG.
• Proficiency in audit-related applications.

Responsibilities

• Analyze and audit claims with ICD-10 expertise.
• Utilize proprietary auditing systems effectively.
• Meet productivity and accuracy standards.

Skills

ICD-9/10CM

Knowledge of medical claims billing

Excellent written communication

Excellent verbal communication

Education

Associate or bachelor’s degree in nursing

Associate or bachelor’s degree in Health Information Management

Tools

Word

Access

Excel

TEAMS

Job description

Overview

This auditing role will focus on Coding & Clinical Chart Validation for our Inpatient audits. The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on the following disciplines from a coding and billing perspective: Inpatient DRG/APR-DRG. This position is responsible for auditing inpatient claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, and the appropriateness of treatment setting and services delivered.

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. Performs work independently.
• Effectively Utilizes Audit Tools. 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. Maintains production goals set by the audit operations management team.
• Meets or Exceed Standards/Guidelines for Accuracy and Quality. 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.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.
• Complete all responsibilities as outlined on annual Performance Plan.
• Complete all special projects and other duties as assigned.
• Must be able to perform duties with or without reasonable accommodation.

Qualifications

Education (at least one of the following are required):

• Associate or bachelor’s degree in nursing (active /unrestricted license).
• Associate or bachelor’s degree Health Information Management (RHIA or RHIT).

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

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

Experience (required):

• 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. Requires expert coding knowledge - DRG, APRDRG, ICD-10, CPT, HCPCS codes.
• Requires working knowledge of and applicable industry-based standards.
• Proficiency in Word, Access, Excel, TEAMS, and other applications.
• Excellent written and verbal communication skills.

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 be able to provide a dedicated, secure work area.
• Must be able to provide high-speed internet access/connectivity and office setup and maintenance.
• No adverse environmental conditions expected.

Base compensation is paid hourly at $45.67 per hour (95k annualized). This role is eligible for discretionary bonus consideration.

Nonexempt employees are eligible to receive overtime pay for hours worked in excess of 40 hours in a given week, or as otherwise required by applicable state law.

Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, 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. For information about our benefits package, please refer to ourCareers page.

Date of posting: 06/20/2025

Applications are assessed on a rolling basis. We anticipate that the application window will close on 08/20/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

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