[Hiring] Senior Auditor Appeals @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.

The auditor performs an extensive review of the initial claim, the associated documentation, and any additional information the provider submits on appeal. Working independently, the auditor 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. The role requires both clinical (nursing) and coding/auditing expertise to substantiate appeal conclusions and support accurate determination outcomes.

The auditor is also proficient in using AI-enabled tools to improve the speed, consistency, and quality of appeals work. The auditor remains accountable for every final determination and written response, follows Cotiviti policy on the responsible use of AI, and protects protected health information (PHI) and client data when using these tools. Because AI-generated content must be reviewed, edited, and fact-checked before use, the auditor exercises sound clinical and professional judgment and never relies on AI output alone.

This position is considered a subject matter expert (SME) in appeals, SNF, IRF, home health, DME, and hospice audits, Medicare coverage criteria, medical necessity guidelines, coding regulations, and appeals processes. The auditor displays professional skepticism and strong analytical skills that strengthen the appeal work performed, and 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.
• Requires expert coding knowledge.
• Working knowledge of Medicare coverage policies, medical necessity guidelines, and appeals regulations.
• Working knowledge of applicable industry-based standards.
• 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, using AI to improve efficiency and quality while applying independent clinical and professional judgment to validate all content.
• 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, including conference calls scheduled to accommodate global time zones.

Benefits

• Base compensation is paid hourly at $47.75 to $57.00 per hour.
• 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, nine paid holidays per year, and 17–27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.