The Auditor, DRG 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.
Key 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.
Requirements:
Education (at least one of the following are required)-
Associates or Bachelor's degree in Nursing (active / unrestricted license)
Associates or Bachelor's degree 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.
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:
Start date for this role will be 9/27/21 or 11/1/21.
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.
For the safety of our employees and those considering employment with Cotiviti, we are currently conducting all interviews virtually. In addition, the majority of the Cotiviti team is currently working remotely, and we are onboarding new hires remotely as well. As we monitor the pandemic, these arrangements may change and we will update accordingly.
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Qualifications
EducationBachelors of Health Administration (preferred) Associates of Health Administration (preferred) Bachelors of Nursing (preferred) Associates of Nursing (preferred) Licenses & CertificationsCCDS: Cert Clin Doc Spec (preferred) RN License (preferred) RHIT: Heath Info Technic (preferred) RHIA: Heath Info Admin (preferred) CPC: Certified Prof Coder (preferred) CCS: Cert Coding Spec (preferred)
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
