Auditor, Coding and Clinical Validation – Episode of Care

Auditor, Coding & Clinical Validation (Episode of Care)

Job Locations: US-Remote

ID2022-9473

Category

Audit – Healthcare

Position Type

Regular

Overview

This is an at home-based position and you must have a work location within the continental US.

The Auditor, Coding & Clinical Validation position has an extensive background in either facility-based nursing and/or inpatient coding and has a high level of understanding in reimbursement guidelines specifically an understanding of the MS-DRG, AP-DRG and APR-DRG payment systems. This position is responsible for auditing inpatient medical records and generating high quality recoverable claims for the benefit of Cotiviti and our clients. Responsible for performing clinical reviews of medical records and other documentation to evaluate issues of coding and DRG assignment accuracy. More specifically, this position will align to EOC (Episode of Care) reviews, performed without a medical record.

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.
• **May Analyze and Audit EOC 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. Review and analyze the billing associated to the entire episode of care including the professional bill as well the inpatient bill. 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.

Qualifications

• Education (at least one of the following is required)-
  • Associates or Bachelor’s degree in Nursing (active/unrestricted license)
  • Associate or Bachelor’s degree in Health Information Management (RHIA or RHIT)
  • 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 Certification (at least one of the following are required and are to be maintained as a condition of employment)
  • RHIA or RHIT
  • Inpatient Coding Credential – CCS or CIC preferred
  • Candidates who hold a CCDS or CPC will be given consideration but will need to obtain an inpatient coding certification within 1 year of their hire date with the company.
• 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.
  • Experience with EOC (Episode of Care) reviews preferred
  • Adherence to official coding guidelines, coding clinic determinations and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge – DRG, ICD-10, CPT, HCPCS codes.
  • Requires working knowledge of and applicable industry based standards.
  • Proficiency in Word, Access, Excel and other applications.
  • Excellent written and verbal communication skills.

Work Environment:

• This is an at home-based position and you must have a work location within the continental US
• This position requires that you provide a high-speed internet connection and a work environment free from distractions (all other equipment will be provided by the company).
• This role is aligned to certain productivity and quality requirements
• Must be able to sit and use a computer keyboard for extended periods of time
• Must have flexibility and willingness to participate in the work processes of an international organization, including conference calls scheduled to accommodate global time zones.

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Cotiviti is an equal employment opportunity employer. Cotiviti recruits, hires and promotes individuals based on their qualifications for a specific job. Cotiviti values its diverse workforce and its selection of employees is made without regard to race, color, creed, sex, age, religion, pregnancy, childbirth or pregnancy-related conditions, national origin, sexual orientation, marital status, genetic carrier status, military service, veteran status, disability, or any other category of class protected by federal, state or local laws. All employment decisions and personnel actions, such as hiring, promotion, compensation, benefits, and termination, are and will continue to be administered in accordance with, and to further the principle of, equal employment opportunity.