[Hiring] Senior Auditor @Cotiviti

Role Description

The Senior Auditor, Appeals is responsible for defending Cotiviti’s recovery determinations and appeals for skilled nursing facility (SNF), inpatient rehabilitation facility (IRF), home health, durable medical equipment (DME), and hospice claims. The auditor applies appropriate guidelines, including Centers for Medicare & Medicaid Services (CMS) inpatient and outpatient coding guidelines, Coding Clinic guidance, and internal clinical validation policies.

• Performs an extensive review of the initial claim, the associated documentation, and any additional information the provider submits on appeal.
• Interprets medical records and applies in-depth knowledge of coding principles, medical necessity criteria, and appeals regulations to render decisions and write clear, well-supported responses.
• Utilizes AI-enabled tools to improve the speed, consistency, and quality of appeals work.
• Exercises sound clinical and professional judgment and never relies on AI output alone.
• Considered a subject matter expert (SME) in appeals, SNF, IRF, home health, DME, and hospice audits.
• Displays professional skepticism and strong analytical skills that strengthen the appeal work performed.
• Stays current on emerging AI capabilities and best practices that can improve audit and appeals workflows.

Qualifications

• Education Required: Associate's or Bachelor's degree in Nursing (active/unrestricted license).
• Coding Certification (Required and to be maintained as a condition of employment): Outpatient Coding Credential (CCS, CCS-P, or CPC).
• Nurses not currently holding coding certification but eligible to sit for the credential will be considered (must obtain within first six months of employment).
• Experience Required: Five+ years of related healthcare experience and auditing experience working with SNF, IRF, Home Health, DME, and Hospice claims.
• Two years of experience as a Cotiviti Auditor Clinical Validation, preferred.
• Experience with appeals processes, defense of audit determinations, and provider communications.
• 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.
• Working knowledge of Medicare coverage policies, medical necessity guidelines, and appeals regulations.
• Proficiency in Word, Access, Excel, and other business applications.
• Excellent written and verbal communication skills.
• Ability to construct clear, factual, and well-supported written responses and communications.
• Ability to work well in individual and team environments.

Requirements

• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of work assigned.
• Remaining in a stationary position, often sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• No adverse environmental conditions expected.
• Must provide high-speed internet access/connectivity and office setup and maintenance.
• Must provide a dedicated, secure work area.
• This is a work-from-home position with work location required within the continental United States.
• Must have flexibility and willingness to participate in work processes of an international organization.

Benefits

• Base compensation is paid hourly at $47.75 to $57.00 per hour.
• 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.
• Competitive benefits package including medical, dental, vision, disability, and life insurance coverage.
• 401(k) savings plans.
• Paid family leave.
• Nine paid holidays per year.
• 17–27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.