DRG Validation Auditor - Off Hours Work (2nd, 3rd, or weekend shift work)

Cotiviti; United States; Remote; USD 52,000 - 74,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Disability insurance

Life insurance

401(k)

Paid family leave

Holidays & PTO

Job summary

Cotiviti seeks a DRG Validation Auditor to perform cross claim clinical reviews and DRG validation for prepay and retrospective audits without medical records. You’ll audit inpatient claims, document results, and ensure coding accuracy and appropriate treatment settings.

The role is full-time with off-hour shifts (3 PM-11 PM or 11 PM-7 AM ET), weekends/holidays, and a base hourly rate of $45.67 with discretionary bonus eligibility.

Qualifications

• Bachelor's degree or nursing degree with active license.
• RHIA, RHIT, CPC or inpatient coding credentials are required and maintained.
• 5+ years of claims auditing, quality assurance or recovery auditing experience.
• Expert knowledge of DRG/ICD-10 coding and CMS guidelines.
• Proficiency in Word, Excel, Access, TEAMS and related tools.
• Strong written and verbal communication skills.

Responsibilities

• Audit inpatient claims focusing on clinical validation and coding accuracy.
• Use Cotiviti audit tools to determine conclusions and issue audit letters.
• Meet productivity and quality standards per the performance plan.
• Identify new claim types and potential recoveries for consideration.
• Contribute to process improvements and special projects.

Skills

ICD-10 Coding

MS-DRG

AP-DRG

APR-DRG

Coding Guidelines

Word

Excel

TEAMS

Communication

Education

RN Nursing Degree

RHIA/RHIT

High School Diploma + 5+ years experience

Tools

Cotiviti auditing systems

MS-Office Suite

Job description

Overview

This DRG Validation Auditor role is focused on our Cross Claim Clinical Reviews (CCCR). Auditors in this role will be doing DRG Validation for our prepay and retrospective audits and making determinations without a medical record. The ideal candidate for this position needs to have both a strong inpatient HIM/coding background and an understanding of clinical validation. 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, services delivered and patient history.

This is a Full-Time role, scheduled to work an off-hour shift from either 3 PM-11 PM or 11 PM-7 AM ET, including weekends & holidays. (No PT or PRN availability)

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.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties, and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and the requirements of the job change.

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).
• High school diploma or GED plus equivalent experience of 5+ years’ experience in claims auditing, quality assurance, or recovery auditing...ideally in a DRG / Clinical Validation Audit setting or a hospital environment.

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.

We anticipate that the application window will close on 12/27/2026.

Date of posting: 10/27/2026