[Hiring] Auditor Clinical Validation @Cotiviti

Role Description

This auditing role will focus on Coding & Clinical Chart Validation for our Outpatient and Specialty audits. 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.

Responsibilities

• Audits Outpatient and Specialty Claims:
  • Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims.
  • Draws on advanced coding 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 advanced proficiency, Cotiviti encoder and audit tools required to perform duties.
  • Enters 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.
• 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.

Qualifications

• Education (required):
  • Associate or bachelor’s degree in nursing (active/unrestricted license)
• Certifications/Licenses (required):
  • Coding Certification required and maintained i.e. CPC, CIC, CCS, CCS-P, RHIA or RHIT.
• 5 to 7 years of experience with clinical medical record coding or auditing and a working knowledge of HIPAA Privacy and Security Rules and CMS security requirements.
• A broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.
• 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.

Requirements

• 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.

Benefits

• Base compensation is paid hourly at $45.67/hour (95k annualized).
• Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs.
• 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
  • 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 our Careers page.