[Hiring] DRG Validation Auditor @Cotiviti

Role Description

This auditing role will focus on Coding & Clinical Chart Validation for our Inpatient audits (DRG Validation). The ideal candidate for this position needs to have both a clinical (nurse) and a coding/auditing background focused on the following disciplines from a coding and billing perspective: Inpatient DRG/APR-DRG. This position is responsible for auditing inpatient claims and documenting the results of those audits, with a focus on clinical review, coding accuracy, and the appropriateness of treatment setting and services delivered.

Start date is 6/1/2026.

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 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 in nursing (active/unrestricted license).
  • Associate or bachelor’s degree in Health Information Management (RHIA or RHIT).
  • High school diploma or GED plus equivalent experience of 5+ years 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, APR-DRG, 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.