[Hiring] Auditor DRG Validation (CMS Audits) @Cotiviti

Role Description

This auditing role will focus on Coding & Clinical Chart Validation for our Inpatient audits. The ideal candidate for this position needs to have a coding/auditing background focused on Inpatient DRG Coding from a coding and billing perspective. This position is responsible for auditing inpatient DRG and documenting the results of those audits with a focus on coding accuracy and the appropriateness of treatment setting and services delivered. This role will start on August 3, 2026.

Responsibilities

• Audits Inpatient DRG Claims:
• Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Inpatient DRG 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 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 Exceeds 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.

Qualifications

• Education (at least one of the following are required):
• 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.

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 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.
• 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.