This auditing role will focus on Coding & Clinical Chart Validation for our Outpatient and Specialty audits....specifically we're hoping to find someone with SNF experience. The ideal candidate for this position needs to have both a clinical (nurse) AND a coding / auditing background focused on one of the following disciplines from a coding and billing perspective: SNF, IRF, Home Health, APC, ER, Diagnostics and Professional Service. This position is responsible for auditing outpatient/specialty claims and documenting the results of those audits. with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting and services delivered.
Key Responsibilities:
Audits Outpatient and Specialty Claims:
Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient and Specialty (SNF, IRF HH) claims.
Draws on advanced clinical expertise and industry knowledge to substantiate conclusions.
Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues.
Effectively Utilizes Audit Tools
Utilizes with advanced proficiency, Cotiviti encoder and audit tools required to perform duties.
Enters the claim into Cotiviti system accurately and in accordance with standard procedures.
Meets or Exceeds Standards/Guidelines for Productivity Maintains production goals, accuracy and quality standards set by the audit for the auditing concept.
Meets or Exceeds Standards/Guidelines for Quality
Achieves the expected level of quality set by the audit for the auditing concept, for valid claim identification and documentation.
Identifies New Claim Types
Identifies potential claims outside of the concept where additional recoveries may be available.
Suggests and develops high quality, high value concepts and/or processes improvement, tools, etc.
Recommends New Concepts and Processes
Has broad in-depth knowledge of client, contract terms and complex claim types gained from extensive healthcare auditing experience.
Suggests, develops and implements new ideas, approaches and/or technological improvements that will support and enhance audit production, communication and client satisfaction.
Evaluates information and draws logical conclusions.
Education/Certifications/Licenses
RN or LPN License required (active / unrestricted in state of residence)
Coding Certification required and maintained i.e. CPC, CIC, CCS, RHIA or RHIT
Skills and Experience
3 - 5 years' professional experience in providing direct patient care.
3 to 5+ years related healthcare experience working with one or more of the following disciplines: SNF, IRF, APC, Home Health, ER, Diagnostics and Professional Service coding reviews.
A broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
Minimum of 3 years of experience with clinical medical record coding or auditing and a working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.
Ability and desire to utilize base coding and clinical auditing knowledge to learn and become proficient in a variety of outpatient and specialty review types.
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.
Excellent verbal and written communication skills.
Ability to work well in an individual and team environment.
Work Environment
This role is aligned to certain productivity & quality metrics
This is a work at home position (US only). Access to high speed internet is required (all other equipment will be provided).
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)
