Clinical Validation Auditor – Outpatient & Specialty Claims

Cotiviti; Northern (KY); Hybrid; USD 107,969,000 - 153,775,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401(k) plan

Paid time off

Job summary

Cotiviti is seeking an experienced auditing professional to focus on Coding & Clinical Chart Validation for Outpatient and Specialty audits. The ideal candidate combines nursing credentials with coding/audit expertise across disciplines such as APC, DRG, and professional services.

The role emphasizes clinical review, coding accuracy, medical necessity, and appropriate treatment settings. It requires strong communication, independent work, and adherence to CMS and HIPAA guidelines.

Qualifications

• Associate or bachelor’s degree in nursing (active/unrestricted license)
• Coding Certification required: CPC, CIC, CCS, CCS-P, RHIA or RHIT
• 5–7 years of clinical medical record coding or auditing experience
• Strong knowledge of HIPAA Privacy and Security Rules and CMS security requirements
• Adherence to official coding guidelines and CMS mandates
• Excellent verbal and written communication skills

Responsibilities

• Audit Outpatient and Specialty Claims using client guidelines (APC, PNPP)
• Apply advanced coding expertise to substantiate conclusions
• Identify new claim types and opportunities for higher recoveries
• Utilize Cotiviti encoder and audit tools; document results in Cotiviti system
• Meet productivity, accuracy and quality standards
• Complete performance plans and special projects as assigned

Skills

Nursing background

Coding auditing

HIPAA knowledge

Communication skills

Education

Nursing degree (Assoc/Bach)

Coding certification (CPC/CIC/CCS/CCS-P/RHIA/RHIT)

Tools

Cotiviti encoder

Audit tools

Job description

Cotiviti is seeking an experienced auditing professional to focus on Coding & Clinical Chart Validation for Outpatient and Specialty audits. The ideal candidate combines nursing credentials with coding/audit expertise across disciplines such as APC, DRG, and professional services.

The role emphasizes clinical review, coding accuracy, medical necessity, and appropriate treatment settings. It requires strong communication, independent work, and adherence to CMS and HIPAA guidelines.